Bastin K, Buchler D, Stitt J, Shanahan T, Pola Y, Paliwal B, Kinsella T
Department of Human Oncology, University of Wisconsin-Madison.
Am J Clin Oncol. 1993 Jun;16(3):256-63.
A comparative analysis of anesthesia use, perioperative morbidity and mortality, capital, and treatment cost of high dose rate versus low dose rate intracavitary brachytherapy for gynecologic malignancy is presented. To assess current anesthesia utilization, application location, and high dose rate afterloader availability for gynecologic brachytherapy in private and academic practices, a nine-question survey was sent to 150 radiotherapy centers in the United States, of which 95 (63%) responded. Of these 95 respondents, 95% used low dose rate brachytherapy, and 18% possessed high dose rate capability. General anesthesia was used in 95% of programs for tandem + ovoid and in 31% for ovoids-only placement. Differences among private and academic practice respondents were minimal. In our institution, a cost comparison for low dose rate therapy (two applications with 3 hospital days per application, operating and recovery room use, spinal anesthesia, radiotherapy) versus high dose rate treatment (five outpatient departmental applications, intravenous anesthesia without an anesthesiologist, radiotherapy) revealed a 244% higher overall charge for low dose rate treatment, primarily due to hospital and operating room expenses. In addition to its ability to save thousands of dollars per intracavitary patient, high dose rate therapy generated a "cost-shift," increasing radiotherapy departmental billings by 438%. More importantly, perioperative morbidity and mortality in our experience of 500+ high dose rate applications compared favorably with recently reported data using low dose rate intracavitary treatment. Capital investment, maintenance requirements, and depreciation costs for high dose rate capability are reviewed. Application of the defined "revenue-cost ratio" formula demonstrates the importance of high application numbers and consistent reimbursement for parity in high dose rate operation. Logically, inadequate third-party reimbursement (e.g., Medicare) reduces high dose rate parity and threatens the future availability of high dose rate technology.
本文对高剂量率与低剂量率腔内近距离放射治疗妇科恶性肿瘤的麻醉使用、围手术期发病率和死亡率、资金投入以及治疗成本进行了比较分析。为评估当前美国私立和学术机构中妇科近距离放射治疗的麻醉使用情况、应用地点以及高剂量率后装治疗机的可用性，向美国150个放疗中心发送了一份包含九个问题的调查问卷，其中95个（63%）做出了回应。在这95位受访者中，95%使用低剂量率近距离放射治疗，18%具备高剂量率治疗能力。95%的治疗方案在使用串联+卵圆体时采用全身麻醉，仅放置卵圆体时31%采用全身麻醉。私立和学术机构受访者之间的差异极小。在我们机构，对低剂量率治疗（每次治疗分两次进行，每次住院3天，使用手术室和恢复室，采用脊髓麻醉及放射治疗）与高剂量率治疗（在门诊进行五次治疗，使用静脉麻醉且无需麻醉医生，采用放射治疗）进行成本比较后发现，低剂量率治疗的总费用高出244%，主要原因是住院和手术室费用。除了能够为每位腔内治疗患者节省数千美元外，高剂量率治疗还产生了“成本转移”，使放疗科的账单增加了438%。更重要的是，在我们超过500例高剂量率治疗的经验中，围手术期发病率和死亡率与最近报道的低剂量率腔内治疗数据相比更具优势。本文还对高剂量率治疗能力的资本投资、维护需求和折旧成本进行了综述。应用定义的“收入成本比”公式表明了高治疗次数以及高剂量率操作中持续报销以实现平价的重要性。从逻辑上讲，第三方报销不足（如医疗保险）会降低高剂量率治疗的平价水平，并威胁到高剂量率技术未来的可用性。
