既往研究已经发现不同医院之间的外科手术成本存在差异，揭示这些差异有助于指导实施减少医疗支出的措施。目前，自体游离皮瓣乳房重建医院差异的经济学后果尚不明确。
2017年7月19日，《美国医学会杂志外科学分册》在线发表密歇根大学的研究报告，对医院之间自体游离皮瓣乳房重建成本差异的影响因素进行了调查。结果发现，在美国进行自体游离皮瓣乳房重建的女性中，虽然规模较大的医院成本较高，但是并发症较少；美国西部与东北部相比，医院资源消耗较多、住院时间较长，尽管患者的术前风险因素较低、并发症发生率相似。因此，有必要进一步调查自体游离皮瓣乳房重建的成本驱动因素；术前低风险患者加快出院可能减少支出而不影响结局。
该全国人群二次横断面分析于2016年9月～2017年2月利用2008～2010年《医疗成本与效用项目》全国住院患者样本数据库，对所有美国社区医院样本进行分层，纳入3302例诊断乳腺癌或乳腺癌高风险并进行自体游离皮瓣乳房重建的女性患者（中位年龄50岁，四分位距：44～57岁），分析指标包括人口统计学数据、医院特征、住院时间、并发症（手术和全身）、住院患者成本，使用单变量和广义线性混合模型检查患者、医院特征、成本之间的相关性。
结果发现，自体游离皮瓣乳房重建的平均成本为22677美元（四分位距：14907～33391美元）。
逻辑回归表明，医院规模与成本增加显著相关（β指数：1.06，95%置信区间：1.02～1.11，P=0.003）。
规模较大（每年≥31例）与较小（每年≤10例）的医院相比：
皮瓣重建成本高（24360比18918美元，P＜0.001）
手术并发症较少（16.4%比23.7%，P＜0.001）
全身并发症较少（24.2%比31.2%，P＜0.001）
西部与东北部相比：
皮瓣手术成本较高（β指数：1.53，95%置信区间：1.46～1.61，P＜0.001）
住院时间显著较长（胜算比：1.25，95%置信区间：1.17～1.33，P＜0.001）
因此，自体游离皮瓣乳房重建患者成本差异显著，经验（根据医院规模进行衡量）可提供优质医疗、并发症较少，但是成本较高。较长的住院时间影响了地区之间的成本差异，并可能成为降低支出而不妨碍医疗的目标。在捆绑式医保支付的时代，应该实施消除成本差异以压缩支出同时仍然提供优质医疗的策略。
JAMA Surg. 2017 Jul 19. [Epub ahead of print]
A Nationwide Analysis of Cost Variation for Autologous Free Flap Breast Reconstruction.
Jessica I. Billig; Yiwen Lu; Adeyiza O. Momoh; Kevin C. Chung.
University of Michigan Health System, Ann Arbor.
This secondary cross-sectional analysis, performed using the Healthcare Cost and Utilization Project National Inpatient Sample database from 2008 to 2010, investigates factors that influence cost variation for autologous free flap breast reconstruction.
QUESTION: What are the variables that contribute to interhospital cost variation in autologous free flap breast reconstruction?
FINDINGS: In this nationwide, population-based secondary cross-sectional analysis that included 3302 women who underwent autologous free flap breast reconstruction in the United States, high-volume hospitals were more costly but had fewer complications. Compared with the Northeast, the West used more hospital resources, with longer length of stay, despite having patients with lower preoperative risk factors and similar complication rates.
MEANING: Further investigation is needed to uncover cost drivers for autologous free flap breast reconstruction; expedited discharge of patients with low preoperative risk factors may be an avenue to decrease expenditure, without compromising outcomes.
IMPORTANCE: Cost variation among hospitals has been demonstrated for surgical procedures. Uncovering these differences has helped guide measures taken to reduce health care spending. To date, the fiscal consequence of hospital variation for autologous free flap breast reconstruction is unknown.
OBJECTIVE: To investigate factors that influence cost variation for autologous free flap breast reconstruction.
DESIGN, SETTING, AND PARTICIPANTS: A secondary cross-sectional analysis was performed using the Healthcare Cost and Utilization Project National Inpatient Sample database from 2008 to 2010. The dates of analysis were September 2016 to February 2017. The setting was a stratified sample of all US community hospitals. Participants were female patients who were diagnosed as having breast cancer or were at high risk for breast cancer and underwent autologous free flap breast reconstruction.
MAIN OUTCOMES AND MEASURES: Variables of interest included demographic data, hospital characteristics, length of stay, complications (surgical and systemic), and inpatient cost. The study used univariate and generalized linear mixed models to examine associations between patient and hospital characteristics and cost.
RESULTS: A total of 3302 patients were included in the study, with a median age of 50 years (interquartile range, 44-57 years). The mean cost for autologous free flap breast reconstruction was $22677 (interquartile range, $14907-$33391). Flap reconstructions performed at high-volume hospitals were significantly more costly than those performed at low-volume hospitals ($24360 vs $18918, P<.001). Logistic regression demonstrated that hospital volume correlated with increased cost (Exp[β], 1.06; 95% CI, 1.02-1.11; P=.003). Fewer surgical complications (16.4% [169 of 1029] vs 23.7% [278 of 1174], P<.001) and systemic complications (24.2% [249 of 1029] vs 31.2% [366 of 1174], P<.001) were experienced in high-volume hospitals compared with low-volume hospitals. Flap procedures performed in the West were the most expensive ($28289), with a greater odds of increased expenditure (Exp[β], 1.53; 95% CI, 1.46-1.61; P<.001) compared with the Northeast. A significant difference in length of stay was found between the West and Northeast (odds ratio, 1.25; 95% CI, 1.17-1.33).
CONCLUSIONS AND RELEVANCE: There is significant cost variation among patients undergoing autologous free flap breast reconstruction. Experience, as measured by a hospital's volume, provides quality health care with fewer complications but is more costly. Longer length of stay contributed to regional cost variation and may be a target for decreasing expenditure, without compromising care. In the era of bundled health care payment, strategies should be implemented to eliminate cost variation to condense spending while still providing quality care.
DOI: 10.1001/jamasurg.2017.2339
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