Ellis S G, Miller D P, Brown K J, Omoigui N, Howell G L, Kutner M, Topol E J
Department of Cardiology, Cleveland Clinic Foundation, OH 44195, USA.
Circulation. 1995 Aug 15;92(4):741-7. doi: 10.1161/01.cir.92.4.741.
Hospital charges associated with percutaneous transluminal coronary revascularization (PTCR) in the United States exceeded $6 billion in 1994 and are likely to be constrained in some manner in the near future. Despite this high cost to the public, little is known about the major determinants and sources of variability of PTCR.
From a consecutive series of 1258 procedures with attempted PTCR at a single tertiary referral center, we analyzed 65 clinical, angiographic, physician, and outcome variables as potential correlates of total (hospital and physician) cost. Direct and indirect costs, both hospital and physician, were determined on the basis of resource utilization using "top-down" methodology and were available for 1237 procedures (1086 patients) (98.3%). Mean (+/- SD) patient age was 62 +/- 11 years, 76% were male, 3% had acute myocardial infarction, 71% had unstable angina, 58% had multivessel disease, left ventricular ejection fraction was 54 +/- 12%, 26% had use of at least one nonballoon revascularization device, and median length of stay was 4.4 days. Procedural success was obtained in 89%, and major complications (death, bypass surgery, or Q-wave myocardial infarction) occurred in 3.8%. The median cost was $9176, but it was asymmetrically distributed, and the interquartile and total ranges were wide ($7333 to $13,845 and $3422 to $193,474, respectively). Analyses of independent correlates of cost and loge(cost) were performed using multivariate linear regression in training and test populations. Modeling found 15 independent preprocedural correlates of loge(cost) (R2 = .37) and 23 overall correlates (R2 = .65), excluding length of stay per se. Additional of length of stay to the model increased the explanatory power of the model to R2 = .82. Preprocedural variables most predictive of loge(cost) included presentation with acute myocardial infarction, decision delay (> 48 hours between admission and diagnostic angiography and/or > 24 hours between angiography and intervention), weekend delay, use of intra-aortic balloon counterpulsation, intention to stent, creatinine > or = 2.0 mg%, and lesion complexity (modified American College of Cardiology/American Heart Association score) (all P < .001). In the model that included postprocedural variables as well, length of stay, noncardiac death, urgent bypass surgery, use of the Rotablator, Q-wave myocardial infarction, rise in creatinine > or = 1.0%, and blood product transfusion were all strong independent correlates of loge(cost) (P < .001).
The range of total hospital costs associated with percutaneous intervention is extraordinarily wide. Baseline patient characteristics account for nearly half of the explained variance, but procedural complications and system delays account for much of the remainder. Quantification of the determinants of cost may promote more economically efficient care in the future.
1994年美国经皮腔内冠状动脉血运重建术（PTCR）的医院收费超过60亿美元，且在不久的将来可能会受到某种程度的限制。尽管公众为此付出了高昂代价，但对于PTCR成本变化的主要决定因素和来源却知之甚少。
在一家单一的三级转诊中心，我们对连续进行的1258例尝试PTCR的手术进行分析，将65项临床、血管造影、医生和结局变量作为总（医院和医生）成本的潜在相关因素。根据资源利用情况，采用“自上而下”的方法确定了医院和医生的直接和间接成本，1237例手术（1086例患者）（98.3%）有相关数据。患者平均（±标准差）年龄为62±11岁，76%为男性，3%发生急性心肌梗死，71%患有不稳定型心绞痛，58%有多支血管病变，左心室射血分数为54±12%，26%至少使用了一种非球囊血管重建装置，中位住院时间为4.4天。手术成功率为89%，主要并发症（死亡、搭桥手术或Q波心肌梗死）发生率为3.8%。中位成本为9176美元，但分布不对称，四分位间距和全距范围较宽（分别为7333美元至13845美元和3422美元至193474美元）。在训练和测试人群中，使用多元线性回归分析成本和loge（成本）的独立相关因素。建模发现loge（成本）有15个术前独立相关因素（R2 = 0.37）和23个总体相关因素（R2 = 0.65），不包括住院时间本身。将住院时间纳入模型后，模型的解释力提高到R2 = 0.82。最能预测loge（成本）的术前变量包括急性心肌梗死表现、决策延迟（入院与诊断性血管造影之间>48小时和/或血管造影与干预之间>24小时）、周末延迟、使用主动脉内球囊反搏、置入支架的意图、肌酐≥2.0mg%以及病变复杂性（改良美国心脏病学会/美国心脏协会评分）（所有P < 0.001）。在同样纳入术后变量的模型中，住院时间、非心源性死亡、紧急搭桥手术、使用旋磨术、Q波心肌梗死、肌酐升高≥1.0%以及输血都是loge（成本）的强独立相关因素（P < 0.001）。
经皮介入相关的医院总成本范围非常广泛。基线患者特征占解释方差的近一半，但手术并发症和系统延迟占其余大部分。对成本决定因素进行量化可能会在未来促进更具经济效率的医疗。
