دانلود رایگان مقاله انگلیسی ارزیابی هزینه لاپارتومی در بیمارستان شهری با استفاده از هزینه یابی مبتنی بر فعالیت زمان محور - وایلی 2018

Background: In low- and middle-income countries, the majority of patients lack access to surgical care due to limited personnel and infrastructure. The Lancet Commission on Global Surgery recommended laparotomy for district hospitals. However, little is known about the cost of laparotomy and associated clinical care in these settings. Methods: This costing study included patients with acute abdominal conditions at three rural district hospitals in 2015 in Rwanda, and used a time-driven activity-based costing methodology. Capacity cost rates were calculated for personnel, location and hospital indirect costs, and multiplied by time estimates to obtain allocated costs. Costs of medications and supplies were based on purchase prices. Results: Of 51 patients with an acute abdominal condition, 19 (37 per cent) had a laparotomy; full costing data were available for 17 of these patients, who were included in the costing analysis. The total cost of an entire care cycle for laparotomy was US$1023⋅40, which included intraoperative costs of US$427⋅15 (41⋅7 per cent) and preoperative and postoperative costs of US$596⋅25 (58⋅3 per cent). The cost of medicines was US$358⋅78 (35⋅1 per cent), supplies US$342⋅15 (33⋅4 per cent), personnel US$150⋅39 (14⋅7 per cent), location US$89⋅20 (8⋅7 per cent) and hospital indirect cost US$82⋅88 (8⋅1 per cent). Conclusion: The intraoperative cost of laparotomy was similar to previous estimates, but any plan to scale-up laparotomy capacity at district hospitals should consider the sizeable preoperative and postoperative costs. Although lack of personnel and limited infrastructure are commonly cited surgical barriers at district hospitals, personnel and location costs were among the lowest cost contributors; similar location-related expenses at tertiary hospitals might be higher than at district hospitals, providing further support for decentralization of these services.

Discussion

Less than half of patients presenting to rural district hospitals in Rwanda with an acute abdominal condition needing laparotomy received surgery locally, in part due to a lack of surgical personnel. These laparotomies were performed only at Butaro District Hospital, where there was a general surgeon on staff.

Limited surgical specialists are often cited as a barrier to accessing surgical care at district hospitals11,16–19. Although the cost of the surgeon’s time contributed about 60 per cent of the total personnel costs, the overall cost of personnel was still lower than that of medicines or supplies. Personnel cost was the third lowest cost contributor overall and the third lowest for the intraoperative costs. Although this is markedly lower than other estimates of personnel-related costs relative to overall inpatient surgical costs19, in this context the cost of the surgeon may not be the limiting factor as much as the deficit of available surgeons. Rwanda has only 0⋅15 general surgeons per 100 000 population10, compared with six per 100 000 population in developed nations20. The country has invested in a Human Resources for Health Program to increase the number of surgical specialists21, and the impact of this training programme should be assessed in the future. More effort is needed in sub-Saharan Africa to train and deploy surgeons to rural settings.

The intraoperative costs of laparotomy in the present study (US$427⋅15) are comparable to a modelling estimate in Ethiopia of US$393⋅819. However, an additional US$596⋅25 was needed to provide the preoperative and postoperative hospital care associated with having a laparotomy. The results of this study bring into question whether surgical services are charging or planning for scale-up at a rate commensurate with the total cost of providing care. Decision-makers who set fee schedules for clinical services should consider these findings. In doing so, hospitals that provide these services will set more appropriate charges for the care they provide and will in turn be able to deliver more surgical care.