Pelletier-Fleury N, Lanoe J L, Fleury B, Fardeau M
Centre de recherches en Economie de la Santé, INSERM U357, CHU de Kremlin-Bicêtre, France.
Chest. 1996 Aug;110(2):411-6. doi: 10.1378/chest.110.2.411.
In greater Paris and its surrounding (as it is in all France), oxygen is home delivered by not-for-profit (NP) associations or profit-making (PM) health organizations. Both are financed by the national health insurance. This dual context and the current economic climate justify an economic evaluation of all respiratory care for patients with COPD receiving long-term oxygen therapy (LTO). This pragmatic approach identifies the variables that have the greatest impact on direct medical costs and estimates the annual cost for respiratory care per COPD patient.
Retrospective study.
Health insurance scheme for self-employed professionals (CANAM).
Between July 1985 and March 1994, 234 patients registered in CANAM files began LTO, 24% in the PM sector, 76% in the NP sector, mainly using concentrator (78%), mean age of 74 +/- 10 years, male predominance (74%), PaO2 of 56.2 +/- 10.5 mm Hg, FEV1/FVC of 43 +/- 15%, and 51% having 1 or more severe illness(es) associated. The economic appraisal was performed on a representative sample of 61 patients and measured the total resources consumption for respiratory care per COPD patient and per year (physician visits and tests, drugs, physiotherapy, oxygen therapy, hospitalizations for acute respiratory failure, transport costs).
A quarter of the patients in each sector did not meet the LTO prescription guidelines (PaO2 > 60 mm Hg). For patients having their oxygen delivered by NP sector, the total ambulatory cost for respiratory care was lower ($4,506 per patient and per year vs $5,399) because they mainly used concentrator, all the other direct ambulatory costs being equal. The total annual cost for respiratory care of a COPD patient receiving LTO amounted to $11,672 (NP and PM sectors merged). Oxygen therapy represented 73% of the total ambulatory cost. In a multiple linear regression model, hospitalization represented the largest share of cost, significantly higher when PaO2 was 55 mm Hg or less ($2,287 per patient per year vs $8,717). In contrast, none of the covariates (age, sex, PaO2, FEV1/FVC) influenced at a significant level the total cost of visits, tests, drugs, and physiotherapy, amounting to $1,507.
As oxygen treatment plays an important role in the variation of costs, further pragmatic studies should help to better understand what are the real motivations to choose one mode of oxygen administration more than another and should determine factors that may lead physicians sometimes not to comply with clinical guidelines.
在大巴黎及其周边地区（法国各地皆是如此），氧气由非营利性（NP）协会或营利性（PM）健康组织提供上门配送服务。二者均由国家医疗保险提供资金支持。这种双重背景以及当前的经济形势，使得对所有接受长期氧疗（LTO）的慢性阻塞性肺疾病（COPD）患者的呼吸护理进行经济评估成为必要。这种务实的方法确定了对直接医疗成本影响最大的变量，并估算了每位COPD患者每年的呼吸护理成本。
回顾性研究。
个体经营专业人员健康保险计划（CANAM）。
在1985年7月至1994年3月期间，CANAM档案中登记的234名患者开始接受长期氧疗，其中24%在营利性部门，76%在非营利性部门，主要使用制氧机（78%），平均年龄为74±10岁，男性占主导（74%），动脉血氧分压（PaO2）为56.2±10.5毫米汞柱，第一秒用力呼气容积/用力肺活量（FEV1/FVC）为43±15%，51%的患者伴有1种或更多种严重疾病。对61名患者的代表性样本进行了经济评估，测量了每位COPD患者每年呼吸护理的总资源消耗（医生诊疗和检查、药物、物理治疗、氧疗、急性呼吸衰竭住院治疗、交通费用）。
每个部门四分之一的患者未达到长期氧疗处方指南（PaO2>60毫米汞柱）。对于由非营利性部门提供氧气的患者，呼吸护理的门诊总费用较低（每位患者每年4506美元，而营利性部门为5399美元），因为他们主要使用制氧机，其他所有门诊直接费用相同。接受长期氧疗的COPD患者每年呼吸护理的总费用为11672美元（非营利性和营利性部门合并计算）。氧疗占门诊总费用的73%。在多元线性回归模型中，住院治疗占成本的比例最大，当PaO2为55毫米汞柱或更低时显著更高（每位患者每年2287美元，而PaO2>55毫米汞柱时为8717美元）。相比之下，没有一个协变量（年龄、性别、PaO2、FEV1/FVC）对诊疗、检查、药物和物理治疗的总成本有显著影响，这部分成本为1507美元。
由于氧疗在成本变化中起着重要作用，进一步的务实研究应有助于更好地理解选择一种氧疗方式而非另一种的真正动机，并应确定可能导致医生有时不遵守临床指南的因素。
