高成本医院的败血症患者存活率似乎并不高

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转中国医院感染管理网杨忠保老师的日志



高成本医院的败血症患者存活率似乎并不高

根据一项发表在2月28日的Archives of Internal Medicine的报告，在高成本的医院，不断增长的住院开支似乎同短期败血症患者较佳的存活率没有联系。

“在美国，每年约有75万败血症患者，同时在许多方面也提供了检验医院支出和患者的治疗效果之间的关系，确定潜在的机会，以改善住院治疗的模型条件” 作者在文章的背景资料中写道。

Tara Lagu, MD, MPH，和同事进行了医院的横断面研究，以确定是否较高的住院费用支出能使败血症患者有较高的生存率。使用透视数据库，他们收集了309家医院2004年6月1日至2006年6月30日期间的至少100例败血症患者的相关数据。

309医院在研究期间收住超过16.69万例病人。病人的平均年龄为70岁，其中52%是女性，大部分（62%）是白人。研究包括的各医院中，大部分（84%）位于市区，一半（49%）在美国南部。

总体而言，33192名患者（20%）在医院死亡。所有医院预期死亡率的中位数率为19.2%。预期死亡率18.5%和19.5%之间的医院，观察到的死亡率介于9.2%至32.3%。总体而言，66家医院（20%）有显著的临床和高于预期的统计死亡率。2家医院观察到了超过预期10－25%的死亡率，46家医院死亡率超过预测值的25%以上。

每个病人的未经调整的平均住院费用中位数为18256美元。超过三分之一（34%）的医院花费超过预计至少10%，每例超支费用中位数为5207美元。在同时研究费用和死亡率时，22家医院（7%）的费用和死亡率均显著低于预期，30家医院（10%）同时高于预期。

作者还确定了一系列提供高价值和低价值医护的机构。22所医院（7%）成本和死亡率均显着低于预期，而105家医院的成本高于预期。这些发现凸显了改善败血症医护价值的潜在机会。例如，63833名在105所医院治疗的病人平均费用高于预期，是一个潜在的3.32亿美元的住院费用超支（用每例超支费用中位数为5207美元计算）。

作者的结论是，“败血症患者的住院费用和调整死亡率差异很大，但较高的支出与更好的生存率无关”。 “努力提高败血症的治疗价值，可参照那些同时获得低于预期的死亡率和住院费用的医院的做法。



High-Cost Hospitals Do Not Appear to Have Better Survival Rates For Sepsis Patients

Increased hospital spending at high-cost hospitals does not appear to be associated with better short-term survival rates for patients with sepsis, according to a report in the February 28 issue of Archives of Internal Medicine.



"Sepsis affects approximately 750,000 patients each year in the United States and is in many ways a model condition for examining the relationship between hospital spending and patient outcomes and for identifying potential opportunities to improve the value of hospital care," the authors write as background information in the article.



Tara Lagu, MD, MPH, of the Baystate Medical Center in Springfield, Mass., and of Tufts University School of Medicine in Boston, and colleagues conducted a cross-sectional study of hospitals to determine whether higher levels of hospital spending were associated with better survival rates for patients with sepsis. Using the Perspective database, data were collected on 309 hospitals that cared for at least 100 patients with sepsis between June 1, 2004 and June 30, 2006.



The 309 hospitals contributed more than 166,900 patients during the study period. The average age of patients was 70 years, 52 percent were women and the majority (62 percent) were white. Of the hospitals included in the study, most (84 percent) were located in urban areas and half (49 percent) were in the southern United States.



Overall, 33,192 patients (20 percent) died while in the hospital. The median expected mortality (death) rate for all hospitals was 19.2 percent. Of the hospitals with expected mortality between 18.5 and 19.5 percent, observed mortality rates ranged from 9.2 to 32.3 percent. Overall, 66 hospitals (21 percent) had a clinically and statistically significant higher-than-expected mortality rate. Twenty hospitals had observed mortality rates between 10 percent and 25 percent above the expected rate and 46 hospitals exceeded predicted mortality by 25 percent.



The median unadjusted hospital average cost per case was $18,256. More than one-third (34 percent) of hospitals exceeded expected costs by at least 10 percent, with a median excess cost per case of $5,207. When examining costs and mortality simultaneously, 22 hospitals (7 percent) had both significantly lower-than-expected costs and mortality rates, and 30 hospitals (10 percent) had both higher-than-expected costs and mortality rates.



The authors also identified a subset of institutions that provided high-value and lower-value care. Twenty-two hospitals (7 percent) had both significantly lower-than-expected costs and mortality rates, while 105 hospitals had higher-than-expected costs. These findings highlight potential opportunities to improve the value of sepsis care. For example, the 63,833 study patients treated at the 105 hospitals with higher than expected mean costs represent a potential $332 million dollars in excess hospital spending (using the median of $5,207 above expected costs).



"Hospital spending and adjusted mortality rates for patients with sepsis vary substantially, but higher hospital expenditures are not associated with better survival," the authors conclude. "Efforts to enhance the value of sepsis care could be modeled on hospitals that achieve lower-than-expected mortality and costs."



Reference: Arch Intern Med. 2011;171[4]:292-299.