Ritchie J L, Maynard C, Chapko M K, Every N R, Martin D C
Department of Medicine, Department of Veterans Affairs, Seattle, Washington, USA.
Am J Cardiol. 1999 Feb 15;83(4):493-7. doi: 10.1016/s0002-9149(98)00901-1.
Studies from a variety of settings have indicated that outcomes for coronary angioplasty are improved when performed in institutions with high caseloads (> 400/year). The purpose of this investigation was to examine the volume outcome hypothesis for coronary angioplasty in a 20% stratified sample of acute care, non-federal hospitals in 17 states. Data were derived from the Nationwide Inpatient Sample from the Health Care Cost and Utilization Project releases 2 and 3. From these records, 163,527 angioplasties from 214 hospitals were selected. Outcomes included hospital mortality, same-admission coronary artery bypass surgery, and a combined end point of either death or same-admission surgery, or both. Hospital volumes were defined as low (< or = 200 cases/year), medium (201 to 400), and high (> 400). Analyses were conducted separately for patients with and without a principal discharge diagnosis of acute myocardial infarction (AMI). For both AMI and no-AMI groups, the rates of adverse outcomes were generally lower in high-volume institutions, and this finding was true in both univariate and multivariate analyses. Although 27% of hospitals were in the low-volume category, only 5% of all procedures were performed in these institutions. Projecting to all United States hospitals for the 2 years, if all procedures performed in low-volume centers had been done in high-volume institutions, 137 deaths could have been averted (90 AMIs, 47 no-AMIs) as well as 404 (46 AMIs, 358 no-AMIs) same-admission surgeries. The results of this study support the hypothesis that better results are obtained in higher volume institutions, but also show that in 1993 and 1994, relatively few patients had their procedures performed in low-volume institutions.
来自各种环境的研究表明，在病例数量多（每年>400例）的机构中进行冠状动脉血管成形术时，其结果会得到改善。本调查的目的是在17个州20%分层抽样的急性护理、非联邦医院中检验冠状动脉血管成形术的手术量-结果假设。数据来源于医疗保健成本和利用项目第2版和第3版发布的全国住院患者样本。从这些记录中，选取了来自214家医院的163,527例血管成形术。结果包括医院死亡率、同次住院冠状动脉搭桥手术，以及死亡或同次住院手术或两者兼有的综合终点。医院手术量被定义为低（≤200例/年）、中（201至400例）和高（>400例）。对有和没有急性心肌梗死（AMI）主要出院诊断的患者分别进行分析。对于AMI组和非AMI组，高手术量机构的不良结果发生率通常较低，这一发现在单变量和多变量分析中均成立。尽管27%的医院属于低手术量类别，但这些机构仅进行了所有手术的5%。将这两年的数据推算至美国所有医院，如果低手术量中心进行的所有手术都在高手术量机构进行，则可避免137例死亡（90例AMI，47例非AMI）以及404例（46例AMI，358例非AMI）同次住院手术。本研究结果支持在手术量较高的机构中能取得更好结果这一假设，但也表明在1993年和1994年，相对较少的患者在低手术量机构接受手术。
