Many scholars have used t-test, chi-squared test, multiple regression analysis, and other methods to explore the influencing factors of hospitalization expenses and achieved certain results [23,24,25]. However, the influencing factors of hospitalization expenses are complex, and there are often correlations between various factors. Path analysis is an extension of multiple regression. It is a structural equation model that does not contain any latent variables [26]. We used path coefficients and standardized direct, indirect, and total effects to accurately assess the impact of each factor on the dependent variable. Path analysis can analyze the direct and indirect effects of various factors on dependent variables, reveal the relationship between variables, and compensate for the regression model’s deficiencies. Therefore, this study adopted this method.
The influence of LOS on hospitalization expenses
As one of the important indicators reflecting the progress of the disease, LOS is the greatest factor influencing the hospitalization expenses of appendicitis patients. The direct effect is 0.535, indicating that the longer LOS, the higher hospitalization expenses. Therefore, to ensure medical quality, how to effectively shorten LOS has become a key issue in reducing hospitalization expenses. The average LOS should be shorted by formulating diagnosis and treatment standards or clinical pathways, optimizing the diagnosis and treatment process, reducing the number of days of hospitalization before surgery and the number of inefficient and ineffective hospitalization days for patients. In addition, patients who meet the standards should be promptly referred to township health centers or community health service centers for rehabilitation, thereby effectively decreasing the postoperative hospital stay. Based on the perspective of health economics, decreasing the number of days in the hospital can expedite hospital bed turnover and increase the medical resources utilization rate; the number of patients admitted to the hospital per unit time will increase, and the total income will increase, which not only reduces average expenses, but also patients’ economic burden.
The influence of surgical grades and methods on hospitalization expenses
The two variables are factors that only had direct effect on hospitalization expenses and the total effect was positive. The result showed an increasing trend as the surgical grades increase, which was consistent with the results of the descriptive analysis. The increase in hospitalization expenses may be related to the increased difficulty of the operation and the increase in medical equipment consumables.
Surgical methods positively correlated with hospitalization expenses, indicating that the average hospitalization expenses of patients undergoing LA were higher than the average hospitalization expenses of patients undergoing OA, which was consistent with the results of the descriptive analysis. LA has been recognized as a surgical technique that can optimize patient safety, quality, and cost [27,28]. The benefits of LA include reduced surgical site infection, less postoperative pain and need for analgesia, and shorter LOS. Long-term benefits include reduced adhesion formation, earlier resumption of normal activities, and cost savings due to earlier resumption of work [27,29,30]. Relevant studies have shown that LA is not fully accepted in some places. This may be because LA requires more manpower and material resources and higher hospital expenses, although it may save money if the patient can resume work faster [30,31,32,33,34]. Prior studies reported a higher incidence of patients with simple appendicitis [35], similar to the results of this study. Analysis of age groups shows that the average LOS of patients does not gradually increase with age. The average LOS of 18 to 33 years old patients is lower than that of other age groups. This may be due to the low coexistence characteristics of young patients, morbidity, and better tolerance to surgical pressure (see Table 6).
Table 6. LA vs OA in appendicitis patients from 0 to 90 years old
Age
(years)
|
LA (N = 1,666)
|
|
OA (N = 498)
|
LOS (days)
|
Hospitalization expenses (CNY)
|
|
LOS (days)
|
Hospitalization expenses (CNY)
|
Average
|
Median
|
Average
|
Median
|
|
Average
|
Median
|
Average
|
Median
|
≦ 17
|
5.26
|
2.22
|
5594.64
|
1127.49
|
|
5.47
|
2.99
|
5308.86
|
1696.03
|
18-33
|
5.19
|
2.42
|
6135.77
|
2429.92
|
|
5.03
|
2.99
|
5694.12
|
1424.63
|
34-52
|
5.61
|
2.72
|
6385.20
|
1952.13
|
|
5.53
|
2.75
|
5834.65
|
1503.01
|
≧ 53
|
6.26
|
2.86
|
6835.89
|
2745.53
|
|
6.95
|
3.43
|
6176.17
|
2507.29
|
The influence of surgical costs, anesthesia costs, disease outcomes, age, and OD on hospitalization expenses
These five variables not only directly affect hospitalization expenses, but also indirectly affect hospitalization expenses through LOS, and the total effect is positive. This demonstrates that hospitalization expenses will increase as surgical and anesthesia costs increase. A series of comprehensive service expenses, medical equipment consumables, and examination and diagnosis expenses incurred during surgery directly led to the increase in hospitalization expenses. To reduce hospitalization expenses, surgeons should improve the level of medical technology, reduce the loss of medical devices, and control unreasonable surgical costs.
The average hospitalization expenses of patients who are converted to other are higher than that of patients who are converted to improved, and the average hospitalization expenses of improved patients are higher than that of cured patients. Patients with better outcomes have a relatively short LOS, consume less medical equipment and medical supplies, and have lower hospitalization expenses. The direct effect is greater than the indirect effect, indicating that the outcome mainly directly affects hospitalization expenses.
Age is uncontrollable and the third major factor affecting hospitalization expenses. Age is positively correlated with hospitalization expenses. This may be due to aging and damage to human organs, as well as the gradual weakening of physical functions with age, various complications, and accompanying diseases, resulting in a relatively long LOS and higher hospitalization expenses. In this regard, the public should increase their awareness of appendicitis and carry out health education, such as avoiding irregular eating, strenuous exercise after meals, spicy and irritating food, and indigestible food such as raw, cold, and hard food. The general public should be instructed to develop good dietary and living habits to fundamentally prevent the occurrence of diseases and achieve early detection and treatment to reduce the economic burden.
Hospitalization expenses will increase as the OD increases. This is not difficult to understand, mainly because of the increase in medical equipment, consumables, and medical supplies.
The influence of acute simple appendicitis and chronic appendicitis on hospitalization expenses
The total effect of these two variables is negative. Compared with patients with acute comorbid appendicitis, patients with acute simple appendicitis have lower average hospitalization expenses. Patients with more serious comorbidities and those with comorbidities have more complicated conditions than patients without comorbidities and will consume more sanitary supplies and medicines during the treatment process, which in turn increases the expenses of medicines. This is inconsistent with the results of the descriptive analysis and may be caused by this study’s small cohort. Studies have shown that for patients undergoing acute appendicitis with abscesses and other complications, conservative treatment is better than immediate surgical treatment at reducing morbidity, hospitalization expenses, and loss of quality of life [36].
Compared with patients with acute comorbid appendicitis, patients with chronic appendicitis have lower average hospitalization expenses. This is consistent with the results of the descriptive analysis. Patients with acute appendicitis have more complicated and urgent conditions than those with chronic appendicitis. During treatment, they will consume more sanitary supplies and medicines, which in turn increases the costs of medicines and inspections and ultimately leads to an increase in hospitalization expenses.
The influence of the total number of surgeons and assistants on hospitalization expenses
The total number of surgeons and assistants only indirectly affects the hospitalization expenses through LOS and is positively correlated with hospitalization expenses. This is inconsistent with the aforementioned descriptive analysis results. It is possible that the path analysis results are more scientific and accurate, so further analysis and research are needed.
The influence of other factors on hospitalization expenses
In this study, the TTA had no significant influence on hospitalization expenses. However, previous studies have shown that hospital work efficiency during weekends is lower than during workdays [37,38,39]. Compared with patients admitted on weekdays, patients admitted on weekends have a higher mortality rate and less reliable diagnostic imaging results [40,41]. Although the incidence of many medical emergencies does not change between workdays and weekends, there are several factors that can negatively affect patient outcomes during workdays and weekends, such as a reduction in the number of medical staff and access to laboratories and diagnostics [42,43]. In addition, inexperienced medical staff and imaging workers can take off work in shifts after work, which may become a problem that reduces the efficiency of medical care on weekends and weekday evenings [44]. Surgery should be scheduled during the day on weekdays, which will help improve the utilization and effectiveness of hospitals’ medical resources and reduce medical expenses [45,46]. Prior studies demonstrated that the readmission rate after appendectomy is estimated to be between 1% and 19% [47,48,49], which showed that improving the efficiency of diagnosis and timely management, especially the value of nursing care, is beneficial to hospitals [50]. Primary medical and health care providers should guide patients to develop good dietary and living habits to reduce the readmission rate and effectively decrease hospitalization expenses.
The path coefficient can be used to calculate the effect of factors that have not been studied but actually have an impact, that is, the remaining path coefficient, which can prompt whether it is necessary to further search for other influencing factors. Pe = 0.699, which is slightly higher than the direct path coefficient of hospitalization days, indicating that there are other factors that have a greater impact on hospitalization costs. This demonstrates that there are still some factors that have a greater impact on hospitalization costs, such as drug expenses and payment methods. There were many missing data in this research, which made the residual path coefficient higher, which was the main limitation of this study. In addition, the cost was related to the economic development grades. This research only selected Anhui province, which has a middle national economic development grade. In the future, the scope of research should be expanded to find national factors in comprehensively developed and undeveloped areas. This was another limitation of this study that should be further researched.