评估囊性纤维化护理的门诊费用的创新:爱尔兰和美国跨多学科护理中心的比较研究。

NEJM catalyst innovations in care delivery Pub Date : 2025-02-01 Epub Date: 2025-01-15 DOI:10.1056/CAT.24.0095
Emma Brady, Ryan C Perkins, Kate Cullen, Gregory S Sawicki, Robert S Kaplan, Gerardine Doyle
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引用次数: 0

摘要

囊性纤维化(CF)影响全球超过16万人,由于多学科护理模式和药物治疗创新,其生存率有所提高。然而,相关成本仍然很大,促使作者研究和评估CF门诊护理的费用,以了解护理结构如何影响成本。在美国和爱尔兰的大型儿童CF中心招募CF (PwCF)患者进行平行观察性前瞻性研究。根据护理过程,两个地点的主要临床医生确定并同意三个层次的患者(0-11个月,1-5岁和6-17岁)。在每个地点为每个年龄组制定了流程图,并利用时间驱动的基于活动的成本法(TDABC)测量了门诊护理的成本,重点是常规CF门诊就诊。计算了护理周期中使用的所有资源的每分钟容量成本率(CCR)。总直接成本是通过将每种资源的CCR乘以在患者护理周期中使用该资源的时间得到的。将所有资源类型的成本相加,以获得每个站点整个护理周期的成本。服务操作以一个站点为基准,并进行方差分析。共有58个PwCF被纳入分析(美国49个,爱尔兰9个);0 ~ 11月龄4例,1 ~ 5岁17例,6 ~ 17岁37例。内科医生(美国)和呼吸科医生(爱尔兰)的ccr最高。与爱尔兰的临床护理专家和营养师相比,美国的医生和注册营养师花在病人身上的时间最多。临床就诊费用的总差异在6至17岁年龄组中最大(差异为28%,美国为100%,爱尔兰为128%)。在6岁至17岁的人群中,总方差的最大驱动因素是数量方差(与患者相处时间的方差),爱尔兰的差异大108%;技能组合方差(临床医生类型在给定时间内执行服务的方差),在美国高出49%;比率差异(不同地点之间的薪酬水平差异),在美国高出31%。作者使用TDABC来描述PwCF门诊就诊期间多学科护理的成本特征,并结合方差分析(对实际成本和预期成本之间差异的定量调查),提供了比较类似医疗保健服务站点成本的新的创新方法,并提供了对每个站点独特特征的见解。对成本的细粒度理解和中心之间资源利用的比较提供了有价值的、与组织相关的见解。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Innovations in Evaluating Ambulatory Costs of Cystic Fibrosis Care: A Comparative Study Across Multidisciplinary Care Centers in Ireland and the United States.

Cystic fibrosis (CF) affects more than 160,000 individuals globally and has seen improved survival rates due to multidisciplinary care models and pharmacotherapy innovations. However, the associated costs remain substantial, prompting the authors to study and evaluate the expense of CF ambulatory care to understand how care structure influences costs. People with CF (PwCF) at large pediatric CF centers in both the United States and Ireland were recruited for parallel observational, prospective studies. Based upon the process of care, the lead clinicians at both sites identified and agreed on three strata of patients (0-11 months, 1-5 years, and 6-17 years of age). Process maps were developed for each of the age cohorts at each site, and the costs of ambulatory care - with emphasis on routine CF clinic visits - were measured utilizing time-driven activity-based costing (TDABC). A dollar-per-minute capacity cost rate (CCR) was calculated for all resources used in the care cycle. The total direct cost was obtained by multiplying the CCR for each resource by the time the resource was used during the patient's care cycle. The cost was summed across all resource types to obtain the cost over the entire care cycle for each site. Service operations were benchmarked to one site and variance analysis was performed. In total, 58 PwCF were included in the analysis (49 in the United States and 9 in Ireland); 4 were 0-11 months, 17 were 1-5 years, and 37 were 6-17 years of age. Physicians (United States) and respiratory consultants (Ireland) had the highest CCRs. Physicians and registered dietitians spent the most time with patients in the United States, compared with the clinical nurse specialists and dietitians in Ireland. The total variance in cost for clinical visits was largest in the 6- to 17-year-old group (28% variance, with 100% in the United States vs. 128% in Ireland). In the 6- to 17-year-old group, the largest drivers in total variance were quantity variance (variance in duration of time spent with patients), which was 108% greater in Ireland); the skill mix variance (variance in clinician type performing service for a given time), which was 49% greater in the United States; and the rate variance (variance in compensation levels across sites), which was 31% greater in the United States. The authors' use of TDABC to characterize the cost of multidisciplinary care during ambulatory clinic visits for PwCF, in combination with variance analysis (the quantitative investigation of the difference between actual and expected costs), provides new and innovative ways to compare costs across similar health care service delivery sites, providing insights into the distinctive features of each. A granular understanding of cost and comparison of resource utilization between centers provides valuable, organizationally relevant insights.

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