围术期医疗模式的术前术后管理要素对髋关节或膝关节置换术患者结局的影响
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The Effect of Implementation of Preoperative and Postoperative Care Elements of a Perioperative Surgical Home Model on Outcomes in Patients Undergoing Hip Arthroplasty or Knee Arthroplasty.
背景与目的
围术期医疗模式(PSH)试图改变美国当前高度分散和昂贵的围术期管理。本卫生服务研究有两个明确的目的，在全髋(THA)或全膝关节置换术(TKA)患者，评估初始PSH模型的术前术后要素与（1）一系列临床结果、质量和病人安全结局以及(2)手术运作和花费之间的联系。
方 法
数据收集策略通过2组前后研究设计,回顾性观察非随机PSH前(PRE-PSH组,N =1225)和PSH后(POST-PSH组,N =1363)。该2研究组来自两连续24个月。应用传统的推理统计检验来评估组差异和关联，包括回归模型。
结 果
与PRE-PSH组相比, POST-PSH组准时开始日间手术增加7.2%(95% CI，4.0%-10.4%,P <0.001)(调整优势比(aOR)2.54;95%CI,1.70-3.80;P <0.001)、日间手术麻醉相关延迟减少5.8%(95%CI,3.1%-8.5%,P <0.001) (优势比0.66;95%CI,0.52-0.84,P <0.001)和 ICU入住率减少2.2% (95%CI,0.5%-3.9%,P = 0.011) (优势比0.45;95%CI,0.31 -0.66,P <0.001)。与 PRE-PSH组相比，POST-PSH组ICU天数减少0.6 (95% CI，0.5,-0.7) (P = 0.028);然而, 2组的住院总时长没有显著性差异(0.1,95%CI,0.1-0.03)之间(P = 0.14)。两组的全因再入院率也没有显著差异(1.2%;95%CI,-0.6-3.0) (P =0.18)。与PRE-PSH组相比,整个POST-PSH组全髋置换直接非手术花费降低432美元(95%CI,270-594) (P <0.001)，全膝置换降低601美元(95%CI,430-772) (P <0.001).
结 论
根据我们的初步结果，麻醉医师作为“围术期医师”的作用扩大，似乎PSH模试与手术运作的改善有关，包括准时开始的手术增加和麻醉相关的延迟减少和日间手术的取消减少，并降低全髋和全膝置换术患者的医疗花费。
原始文献摘要
Vetter TR, Barman J, Hunter JM Jr,et al. The Effect of Implementation of Preoperative and Postoperative Care Elements of a Perioperative Surgical Home Model on Outcomes in Patients Undergoing Hip Arthroplasty or Knee Arthroplasty.[J]. Anesth Analg, 2017 May;124(5):1450-1458.
BACKGROUND:The Perioperative Surgical Home (PSH) seeks to remedy the currently highly fragmented and expensive perioperative care in the United States. The 2 specific aims of this health services research study were to assess the association between the preoperative and postoperative elements of an initial PSH model and a set of (1) clinical, quality, and patient safety outcomes and (2) operational and financial outcomes, in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA).
METHODS:A 2-group before-and-after study design, with a nonrandomized preintervention PSH (PRE-PSH group, N = 1225) and postintervention PSH (POST-PSH group, N = 1363) data-collection strategy, was applied in this retrospective observational study. The 2 study groups were derived from 2 sequential 24-month time periods. Conventional inferential statistical tests were applied to assess group differences and associations, including regression modeling.
RESULTS:Compared with the PRE-PSH group, there was a 7.2% (95% confidence interval [CI], 4.0%-10.4%, P < .001) increase in day of surgery on-time starts (adjusted odds ratio [aOR] 2.54; 95% CI, 1.70-3.80; P < .001); a 5.8% (95% CI, 3.1%-8.5%, P < .001) decrease in day of surgery anesthesia-related delays (aOR 0.66; 95% CI, 0.52-0.84, P < .001); and a 2.2% (95% CI, 0.5%-3.9%, P = .011) decrease in ICU admission rate (aOR 0.45; 95% CI, 0.31-0.66, P < .001) in the POST-PSH group. There was a 0.6 (95% CI, 0.5-0.7) decrease in the number of ICU days in the POST-PSH group compared with the PRE-PSH group (P = .028); however, there was no significant difference (0.1 day; 95% CI, -0.03 to 0.23) in the total hospital length of stay between the 2 study groups (P = .14). There was also no significant difference (1.2%; 95% CI, -0.6 to 3.0) in the all-cause readmission rate between the study groups (P = .18). Compared with the PRE-PSH group, the entire POST-PSH group was associated with a $432 (95% CI, 270-594) decrease in direct nonsurgery costs for the THA (P < .001) and a $601 (95% CI, 430-772) decrease in direct nonsurgery costs for the TKA (P < .001) patients.
CONCLUSIONS：On the basis of our preliminary findings, it appears that a PSH model with its expanded role of the anesthesiologist as the "perioperativist" can be associated with improvements in the operational outcomes of increased on-time surgery starts and reduced anesthesia-related delays and day-of-surgery case cancellations, and decreased selected costs in patients undergoing THA and TKA.
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