Zehr K J, Dawson P B, Yang S C, Heitmiller R F
Division of Thoracic Surgery, Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
Ann Thorac Surg. 1998 Sep;66(3):914-9. doi: 10.1016/s0003-4975(98)00662-6.
Standardized clinical care pathways have been developed for postoperative management in an attempt to contain costs in an era of rising health care costs and limited resources. The purpose of this study was to assess the effect of these pathways on length of stay, hospital charges, and outcome for major thoracic surgical procedures.
All anatomic lung (segmentectomy, lobectomy, and pneumonectomy) and partial and complete esophageal resections performed from July 1991 to July 1997 were retrospectively analyzed for length of stay, hospital charges, and outcome. A prospectively developed database was used. Clinical care pathways were introduced in March 1994. Comparisons were made between the procedures performed before (group I) and after (group II) pathway implementation. Common to both pathways are early mobilization and prudent x-ray and laboratory analysis. In addition, the pathway for esophagectomies emphasizes overnight intubation with 24-hour intensive care unit care, and staged diet advancement. The discharge goal was postoperative day 10. For lung resection the emphasis is early postoperative extubation with overnight intensive care unit management. The discharge goal was postoperative day 7.
Group I esophagectomies (n = 56) had significantly greater hospital charges compared with group II (n = 96) ($21,977 +/- $13,555 versus $17,919 +/- $5,321; p < 0.04, in actual dollars) and ($29,097 +/- $18,586 versus $19,260 +/- $6,000; p < 0.001, in dollars adjusted for inflation) and greater length of stay (13.6 +/- 6.9 versus 9.5 +/- 2.8 days; p < 0.001). Group I lung resections (n = 185) had a significantly greater length of stay compared with group II (n = 241) (8.0 +/- 6.2 versus 6.4 +/- 3.8 days; p < 0.002); although charges trended downward ($13,113 +/- $10,711 versus $12,404 +/- $7,189; not significant) in actual dollars, charges were significantly less in dollars adjusted for inflation ($17,103 +/- $13,211 versus $13,432 +/- $8,056; p < 0.01). The most significant decreases in charges for esophagectomies were in miscellaneous charges (61% in dollars adjusted for inflation), pharmaceuticals (60%), laboratory (42%) and radiologic (39%) tests, physical therapy charges (35%), and routine charges (34%). For lung resections the greatest savings occurred for pharmaceuticals (38%), supplies (34%), miscellaneous charges (25%), and routine charges (22%). Mortality was similar (esophagectomies: I, 3.6%; II, 0%; lung resections: I, 0.5%; II, 0.8%; not significant).
Introduction of standardized clinical pathways has resulted in a marked reduction of length of stay for all major thoracic surgical procedures. Total charges were reduced for both esophagectomies (34%) and lung resections (21%) with continued quality of outcome.
在医疗费用不断上涨且资源有限的时代，为控制成本已制定了标准化临床护理路径用于术后管理。本研究的目的是评估这些路径对主要胸外科手术的住院时间、医院收费及结局的影响。
对1991年7月至1997年7月期间进行的所有解剖性肺手术（肺段切除术、肺叶切除术和全肺切除术）以及部分和完全食管切除术的住院时间、医院收费及结局进行回顾性分析。使用了一个前瞻性建立的数据库。临床护理路径于1994年3月引入。对路径实施前（I组）和实施后（II组）进行的手术进行比较。两种路径的共同之处在于早期活动及谨慎的X线和实验室检查。此外，食管切除术路径强调术后过夜插管并在重症监护病房护理24小时，以及分阶段推进饮食。出院目标是术后第10天。对于肺切除术，重点是术后早期拔管并在重症监护病房进行过夜管理。出院目标是术后第7天。
I组食管切除术（n = 56）与II组（n = 96）相比，医院收费显著更高（实际美元：$21,977 ± $13,555对$17,919 ± $5,321；p < 0.04，经通胀调整后的美元：$29,097 ± $18,586对$19,260 ± $6,000；p < 0.001），住院时间更长（13.6 ± 6.9天对9.5 ± 2.8天；p < 0.001）。I组肺切除术（n = 185）与II组（n = 241）相比，住院时间显著更长（8.0 ± 6.2天对6.4 ± 3.8天；p < 0.002）；尽管实际美元收费呈下降趋势（$13,113 ± $10,711对$12,404 ± $7,189；无显著性差异），但经通胀调整后的美元收费显著更低（$17,103 ± $13,211对$13,432 ± $8,056；p < 0.01）。食管切除术收费下降最显著的是杂项收费（经通胀调整后的美元中下降61%）、药品（60%）、实验室（42%）和放射学（39%）检查、物理治疗收费（35%）以及常规收费（34%）。对于肺切除术，节省最多的是药品（38%）、耗材（34%）、杂项收费（25%）和常规收费（22%）。死亡率相似（食管切除术：I组，3.6%；II组，0%；肺切除术：I组，0.5%；II组，0.8%；无显著性差异）。
引入标准化临床路径已使所有主要胸外科手术的住院时间显著缩短。食管切除术（34%）和肺切除术（21%）的总收费均有所降低，且结局质量持续保持。
