Traverso L W
Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA.
Surg Clin North Am. 1996 Jun;76(3):631-9. doi: 10.1016/s0039-6109(05)70469-2.
"Quality first and costs second" should be our motto. As surgeons we need to get involved with our procedures, but with the knowledge of the strengths and weaknesses of both outcome and cost analysis-that is, value assessment. The key to evaluating a procedure is to determine its value. This can be done only by physicians cognizant of the disease process and value assessment. The value is determined by assessing a procedure's utilization, outcomes, and costs. Utilization allows early treatment and avoids neglected disease. Therefore, the appropriateness of the utilization can be determined only by an outcome study. An outcome study is another term for quality assessment. Outcomes deal with morbidity, mortality, and the long- and short-term effects of the procedure. Overall, an increase of quality in a global perspective decreases the costs of the procedure to the health care community. Costs must remain secondary to outcomes. A cost analysis of LC has shown that surgeons can influence the majority of OR costs, and these are the direct variable type. Costs are usually not comparable between hospitals. Within each hospital, costs can be successfully used to assess efficiency and demand elasticity. An attempt to decrease costs directly is a maneuver that, when applied solely by nonmedical individuals, will most likely decrease quality. When the quality can be maintained (as assessed only by a practitioner), then a decrease in global costs increases value. The concept of increasing value by increasing quality without an attempt to decrease costs is a very important principle that the health care system must learn in our ever-challenging medical environment. Business administrators have decreased costs without consideration of quality assessment. Consider the additional impact of taking these cost savings and paying dividends to investors rather than reinvesting the monies into medical research or new technology. Quality declines first in patient choice, then referring physician choice, and finally short- and long-term results. When will this decline be apparent if quality assessments are not completed concurrently with cost analysis?
“质量第一，成本第二”应是我们的座右铭。作为外科医生，我们需要参与手术过程，但要了解结果分析和成本分析（即价值评估）的优缺点。评估手术的关键在于确定其价值。这只能由了解疾病过程和价值评估的医生来完成。价值是通过评估手术的利用率、结果和成本来确定的。利用率能实现早期治疗并避免疾病被忽视。因此，只有通过结果研究才能确定利用率是否恰当。结果研究是质量评估的另一种说法。结果涉及发病率、死亡率以及手术的长期和短期影响。总体而言，从全球角度提高质量会降低医疗保健机构的手术成本。成本必须始终次于结果。一项腹腔镜胆囊切除术（LC）的成本分析表明，外科医生能够影响大部分手术室成本，而且这些是直接可变成本类型。不同医院之间的成本通常不可比。在每家医院内部，成本可成功用于评估效率和需求弹性。直接降低成本的尝试，如果仅由非医疗人员进行，很可能会降低质量。当质量能够维持（仅由从业者评估）时，那么全球成本的降低会增加价值。在不试图降低成本的情况下通过提高质量来增加价值的理念是医疗保健系统在我们这个充满挑战的医疗环境中必须学习的一个非常重要的原则。企业管理人员在不考虑质量评估的情况下降低了成本。想想将这些成本节省用于向投资者支付股息而不是再投资于医学研究或新技术所带来的额外影响。质量首先在患者选择方面下降，然后是转诊医生的选择，最后是短期和长期结果。如果质量评估不同时与成本分析一起完成，这种下降何时会显现出来呢？
