加速康复外科模式在全髋关节置换术围术期管理中的临床研究
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摘要
目的评价加速康复外科(enhanced recovery after surgery, ERAS)模式在全髋关节置换术围术期管理中的临床效果及康复效益。方法回顾性提取2013～2016年四川大学华西医院生物医学大数据研究中心数据库中行全髋关节置换术病例的数据,比较采用ERAS模式(ERAS组)与采用传统模式(传统组)管理围术期全髋关节置换术患者康复质量指标、康复效率指标、住院费用指标的差异。结果纳入全髋关节置换术患者共915例,其中ERAS组497例,传统组418例;与传统模式相比,ERAS模式能够降低全髋关节置换术总体并发症发生率(8.6%vs.4.8%,P<0.05),也能降低深静脉血栓及肺部感染发生率(3.1%、0.8%vs.2.4%、0.6%,P<0.05);可以缩短平均住院时间[(10.9±2.9) d vs.(7.6±2.0) d,P=0.039];术后平均住院时间更低[(8.6±2.0) d vs.(5.6±0.9) d,P=0.028)];降低住院总费用4.8%～7.1%(P<0.05),其中药品费降幅达17.2%～24.9%(P<0.05)。结论 ERAS模式能够促进患者术后安全快速康复,减少住院费用,控制医疗成本。
Objective To evaluate the clinical effect and rehabilitation benefit of enhanced recovery after surgery(ERAS) model in perioperative management of total hip arthroplasty(THA). Methods A retrospective study were conducted in THA patients from the database of big data Research Center of Biomedicine, West China Hospital of Sichuan University from 2013 to 2016. The differences of rehabilitation quality, rehabilitation efficiency and hospitalization cost between ERAS model(ERAS group) and traditional model(traditional group) were compared. Results 915 THA patients were included in the study, of which 497 patients were given ERAS peri-operative management and 418 patients in the traditional group. The rate of overall complications in the ERAS group was significantly lower than that in the traditional group(4.8% vs. 8.6%,P<0.05), with lower rate of deep venous thrombosis(0.8% vs. 3.1%) and pulmonary infection(0.6% vs. 2.4%) in the ERAS group. Compared with the traditional group, the average length of stay in hospital was shorter in the ERAS group [(7.6±2.0) d vs.(10.9±2.9) d, P=0.039], as well as postoperative length of stay in hospital [(5.6±0.9) d vs.(8.6±2.0) d, P=0.028)]. And the ERAS model reduced the total hospitalization cost by 4.8% to 7.1%(P<0.05), of which the drug cost decreased by 17.2% to 24.9%(P<0.05). Conclusion ERAS model in THA is safe and effective. It can reduce hospitalization cost and help to control medical cost.
Objective To evaluate the clinical effect and rehabilitation benefit of enhanced recovery after surgery(ERAS) model in perioperative management of total hip arthroplasty(THA). Methods A retrospective study were conducted in THA patients from the database of big data Research Center of Biomedicine, West China Hospital of Sichuan University from 2013 to 2016. The differences of rehabilitation quality, rehabilitation efficiency and hospitalization cost between ERAS model(ERAS group) and traditional model(traditional group) were compared. Results 915 THA patients were included in the study, of which 497 patients were given ERAS peri-operative management and 418 patients in the traditional group. The rate of overall complications in the ERAS group was significantly lower than that in the traditional group(4.8% vs. 8.6%,P<0.05), with lower rate of deep venous thrombosis(0.8% vs. 3.1%) and pulmonary infection(0.6% vs. 2.4%) in the ERAS group. Compared with the traditional group, the average length of stay in hospital was shorter in the ERAS group [(7.6±2.0) d vs.(10.9±2.9) d, P=0.039], as well as postoperative length of stay in hospital [(5.6±0.9) d vs.(8.6±2.0) d, P=0.028)]. And the ERAS model reduced the total hospitalization cost by 4.8% to 7.1%(P<0.05), of which the drug cost decreased by 17.2% to 24.9%(P<0.05). Conclusion ERAS model in THA is safe and effective. It can reduce hospitalization cost and help to control medical cost.
引文
[1] 戴尅戎,李慧武,严孟宁.我国人工关节加速发展的二十年.中华关节外科杂志(电子版),2015(6):1-4[2018-09-21].http://www.cnki.com.cn/ Article/CJFDTotal- ZHGJ201506002.htm.
[2] KEHLET H.Multimodal approach to control postoperative pathophysiology and rehabilitation.Br J Anaesth,1997,78(5):606-617.
[3] 黎介寿.对Fast-track surgery内涵的认识.中华普外科手术学杂志(电子版),2007,1(1):1-2[ 2018-09-21].http://www.wanfangdata.com.cn/details/ detail.do?_ type=perio&id=zhptwksszz200701001.
[4] 周宗科,翁习生,曲铁兵,等.中国髋、膝关节置换术加速康复——围术期管理策略专家共识.中华骨与关节外科杂志,2016,9(1):1-9.
[5] 任钦,李晓松,周晓媛.心血管介入疗法成本效用分析.卫生经济研究,2014(12)[2018-09-21].http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id= wsjjyj201412013.doi:10.14055/j.cnki.33-1056/f.20141125.001.
[6] 冯金华,李立,汪晓东,等.加速康复外科对结直肠癌患者术后炎性反应及细胞免疫功能影响的随机对照研究.四川大学学报(医学版),2016,47(1) (1):131-134.
[7] GROCOTT MP,DUSHIANTHAN A,HAMILTON MA,et al.Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery:a Cochrane Systematic Review.Br J Anaesth,2013,111(4):535-548.
[8] PEARSE EO,CALDWELL BF,LOCKWOOD RJ,et al.Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism.J Bone Joint Surg Br,2007,89(3):316-322.
[9] 华政哲,刘欣伟,张敬东,等.加速康复外科理念在膝关节置换术围术期应用.临床军医杂志,2016,44(10):1022-1024.
[10] 陈志,李金龙,于浩达,等.快速康复理念运用于初次全髋关节置换术的有效性评价.实用骨科杂志,2016,22(7):586-590.
[11] KEHLET H.Fast-track hip and knee arthroplasty.Lancet,2013,381(9878):1600-1602.
[12] 张惠平,徐玉莲,黄红波.入院检查前移缩短平均住院日的实践与效果分析.全科医学临床与教育,2015,13(2):239-240.
[13] 朱金燕,侯旭敏,马进.上海某三甲专科医院心内科代表性病种入院及住院日无效性研究.中国心血管病研究,2016,14(3):272-276.
[14] WANG C,CHEN HN,ZHOU ZG.Two-day hospital stay after laparoscopic colorectal surgery:is enhanced recovery program a healthcare system-specific issue?World J Surg,2015,39(5):1329-1330.
[15] 付丽敏,杨小华,吕永明,等.加速康复外科在全膝置换患者康复治疗中的应用.中国组织工程研究与临床康复,2011,15(22):4019-4022.
[16] MCDONALD DA,SIEGMETH R,DEAKIN AH,et al.An enhanced recovery programme for primary total knee arthroplasty in the United Kingdom-follow up at one year.Knee,2012,19(5):525-529.
[17] GEERTS WH,BERGQVIST D,PINEO GF,et al.Prevention of venous thromboembolism:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).Chest,2008,133 (Suppl 6):381S-453S.
[18] KJAERSGAARD-ANDERSEN P,KEHLET H.Should deep venous thrombosis prophylaxis be used in fast-track hip and knee replacement?Acta Orthop,2012,83(2):105-106.
[19] 王锴,林剑浩.实施临床路径管理前后全髋关节置换术住院费用的对比研究.中华骨科杂志,2014,34(6):612-618.
[20] TANIGUCHI H,SASAKI T,FUJITA H,et al.Modified ERAS protocol using preoperative oral rehydration therapy:outcomes and issues.J Anesth,2014,28(1):143-147.
[2] KEHLET H.Multimodal approach to control postoperative pathophysiology and rehabilitation.Br J Anaesth,1997,78(5):606-617.
[3] 黎介寿.对Fast-track surgery内涵的认识.中华普外科手术学杂志(电子版),2007,1(1):1-2[ 2018-09-21].http://www.wanfangdata.com.cn/details/ detail.do?_ type=perio&id=zhptwksszz200701001.
[4] 周宗科,翁习生,曲铁兵,等.中国髋、膝关节置换术加速康复——围术期管理策略专家共识.中华骨与关节外科杂志,2016,9(1):1-9.
[5] 任钦,李晓松,周晓媛.心血管介入疗法成本效用分析.卫生经济研究,2014(12)[2018-09-21].http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id= wsjjyj201412013.doi:10.14055/j.cnki.33-1056/f.20141125.001.
[6] 冯金华,李立,汪晓东,等.加速康复外科对结直肠癌患者术后炎性反应及细胞免疫功能影响的随机对照研究.四川大学学报(医学版),2016,47(1) (1):131-134.
[7] GROCOTT MP,DUSHIANTHAN A,HAMILTON MA,et al.Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery:a Cochrane Systematic Review.Br J Anaesth,2013,111(4):535-548.
[8] PEARSE EO,CALDWELL BF,LOCKWOOD RJ,et al.Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism.J Bone Joint Surg Br,2007,89(3):316-322.
[9] 华政哲,刘欣伟,张敬东,等.加速康复外科理念在膝关节置换术围术期应用.临床军医杂志,2016,44(10):1022-1024.
[10] 陈志,李金龙,于浩达,等.快速康复理念运用于初次全髋关节置换术的有效性评价.实用骨科杂志,2016,22(7):586-590.
[11] KEHLET H.Fast-track hip and knee arthroplasty.Lancet,2013,381(9878):1600-1602.
[12] 张惠平,徐玉莲,黄红波.入院检查前移缩短平均住院日的实践与效果分析.全科医学临床与教育,2015,13(2):239-240.
[13] 朱金燕,侯旭敏,马进.上海某三甲专科医院心内科代表性病种入院及住院日无效性研究.中国心血管病研究,2016,14(3):272-276.
[14] WANG C,CHEN HN,ZHOU ZG.Two-day hospital stay after laparoscopic colorectal surgery:is enhanced recovery program a healthcare system-specific issue?World J Surg,2015,39(5):1329-1330.
[15] 付丽敏,杨小华,吕永明,等.加速康复外科在全膝置换患者康复治疗中的应用.中国组织工程研究与临床康复,2011,15(22):4019-4022.
[16] MCDONALD DA,SIEGMETH R,DEAKIN AH,et al.An enhanced recovery programme for primary total knee arthroplasty in the United Kingdom-follow up at one year.Knee,2012,19(5):525-529.
[17] GEERTS WH,BERGQVIST D,PINEO GF,et al.Prevention of venous thromboembolism:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).Chest,2008,133 (Suppl 6):381S-453S.
[18] KJAERSGAARD-ANDERSEN P,KEHLET H.Should deep venous thrombosis prophylaxis be used in fast-track hip and knee replacement?Acta Orthop,2012,83(2):105-106.
[19] 王锴,林剑浩.实施临床路径管理前后全髋关节置换术住院费用的对比研究.中华骨科杂志,2014,34(6):612-618.
[20] TANIGUCHI H,SASAKI T,FUJITA H,et al.Modified ERAS protocol using preoperative oral rehydration therapy:outcomes and issues.J Anesth,2014,28(1):143-147.