Macario A, Vitez T S, Dunn B, McDonald T, Brown B
Department of Anesthesia and Health Research and Policy, Stanford University Medical Center, California 94305-5115, USA. macario_
Anesthesiology. 1997 Jan;86(1):92-100. doi: 10.1097/00000542-199701000-00013.
If patients who are more severely ill have greater hospital costs for surgery, then health-care reimbursements need to be adjusted appropriately so that providers caring for more seriously ill patients are not penalized for incurring higher costs. The authors' goal for this study was to determine if severity of illness, as measured by either the American Society of Anesthesiologists Physical Status (ASA PS) or the comorbidity index developed by Charlson, can predict anesthesia costs, operating room costs, total hospital costs, or length of stay for elective surgery.
The authors randomly selected 224 inpatients (60% sampling fraction) having either colectomy (n = 30), total knee replacement (n = 100), or laparoscopic cholecystectomy (n = 94) from September 1993 to September 1994. For each surgical procedure, backward-elimination multiple regression was used to build models to predict (1) total hospital costs, (2) operating room costs, (3) anesthesia costs, and (4) length of stay. Explanatory candidate variables included patient age (years), sex, ASA PS, Charlson comorbidity index (which weighs the number and seriousness of coexisting diseases), and type of insurance (Medicare/Medicaid, managed care, or indemnity). These analyses were repeated for the pooled data of all 224 patients. Costs (not patient charges) were obtained from the hospital cost accounting software.
Mean total hospital costs were $3,778 (95% confidence interval +/- 299) for laparoscopic cholecystectomy, $13,614 (95% CI +/- 3,019) for colectomy, and $18,788 (95% CI +/- 573) for knee replacement. The correlation (r) between ASA PS and Charlson comorbidity scores equaled 0.34 (P < .001). No consistent relation was found between hospital costs and either of the two severity-of-illness indices. The Charlson comorbidity index (but not the ASA PS) predicted hospital costs only for knee replacement (P = .003). The ASA PS, but not the Charlson index, predicted operating room and anesthesia costs only for colectomy (P < .03).
Severity of illness, as categorized by ASA PS categories 1-3 or by the Charlson comorbidity index, was not a consistent predictor of hospital costs and lengths of stay for three types of elective surgery. Hospital resources for these lower-risk elective procedures may be expended primarily to manage the consequences of the surgical disease, rather than to manage the patient's coexisting diseases.
如果病情较重的患者手术的医院费用更高，那么医疗保健报销需要进行适当调整，以使照顾病情更严重患者的医疗服务提供者不会因成本增加而受到惩罚。作者进行这项研究的目的是确定疾病严重程度，以美国麻醉医师协会身体状况（ASA PS）或Charlson制定的合并症指数来衡量，是否可以预测择期手术的麻醉费用、手术室费用、总医院费用或住院时间。
作者从1993年9月至1994年9月随机选择了224名住院患者（抽样比例为60%），他们分别接受结肠切除术（n = 30）、全膝关节置换术（n = 100）或腹腔镜胆囊切除术（n = 94）。对于每种手术，采用向后逐步回归法建立模型来预测：（1）总医院费用；（2）手术室费用；（3）麻醉费用；（4）住院时间。解释性候选变量包括患者年龄（岁）、性别、ASA PS、Charlson合并症指数（该指数权衡了并存疾病的数量和严重程度）以及保险类型（医疗保险/医疗补助、管理式医疗或赔偿保险）。对所有224名患者的汇总数据重复进行这些分析。费用（而非患者收费）来自医院成本核算软件。
腹腔镜胆囊切除术的平均总医院费用为3778美元（95%置信区间±299），结肠切除术为13614美元（95%置信区间±3019），膝关节置换术为18788美元（95%置信区间±573）。ASA PS与Charlson合并症评分之间的相关性（r）为0.34（P <.001）。未发现医院费用与两种疾病严重程度指数中的任何一种之间存在一致的关系。Charlson合并症指数（而非ASA PS）仅能预测膝关节置换术的医院费用（P =.003）。ASA PS而非Charlson指数仅能预测结肠切除术的手术室和麻醉费用（P <.03）。
以ASA PS 1 - 3级分类或Charlson合并症指数分类的疾病严重程度，并非三种择期手术医院费用和住院时间的一致预测指标。这些低风险择期手术的医院资源可能主要用于处理手术疾病的后果，而非处理患者的并存疾病。
