Finlayson Emily V A, Birkmeyer John D
VA Outcomes GrouP, Department of Veterans Affairs Medical Center, White River Junction, VT, USA.
J Am Coll Surg. 2003 Mar;196(3):410-7. doi: 10.1016/S1072-7515(02)01753-2.
In addition to lower operative mortality, patients undergoing selected cancer operations at high volume centers have improved longterm survival. We sought to determine the overall effect of hospital volume on life expectancy after cancer surgery.
We used a Markov decision analysis model to estimate life expectancy for patients undergoing resection for pancreatic, lung, or colon cancer. Model inputs included probabilities of operative mortality and longterm survival. For input data, we examined operative mortality (in-hospital or within 30 days) stratified by volume in over 400,000 patients undergoing resection for these three cancers using the national Medicare database (1994-1999). Risks of late mortality were abstracted from published studies (MEDLINE, 1966 to present) to model the effect of hospital volume on longterm survival. In analysis, we first calculated life expectancy for patients undergoing surgery at very low, low, medium, high, and very high volume hospitals. We then explored the effects of various regionalization strategies.
Life expectancy increased steadily with hospital volume for all three cancers. Life expectancy after pancreatic cancer resection increased linearly with hospital volume: from 1.9 years at very low volume centers to 3.6 years at very high volume centers. For lung cancer, life expectancy ranged from 5.4 to 6.6 years. Increases in life expectancy for colon cancer were not as dramatic: from 6.8 at very low volume hospitals to 7.4 years at very high volume hospitals. Differences in life expectancy across volume strata were largely attributable to differences in longterm survival, not operative mortality. From a policy perspective, regionalizing surgery for colon cancer would produce the greatest overall life-expectancy gains, but it would require moving most patients.
Patients aged 65 and older with pancreatic, lung, and colon cancer have substantially greater life expectancy after cancer resection at higher volume hospitals. Further work is needed to understand the mechanisms underlying differences in performance across hospitals in cancer care.
除了手术死亡率较低外，在高容量中心接受特定癌症手术的患者长期生存率也有所提高。我们试图确定医院容量对癌症手术后预期寿命的总体影响。
我们使用马尔可夫决策分析模型来估计接受胰腺癌、肺癌或结肠癌切除术患者的预期寿命。模型输入包括手术死亡率和长期生存率的概率。对于输入数据，我们使用国家医疗保险数据库（1994 - 1999年）检查了超过40万例接受这三种癌症切除术患者的手术死亡率（住院期间或30天内），按容量分层。晚期死亡率风险从已发表的研究（MEDLINE，1966年至今）中提取，以模拟医院容量对长期生存的影响。在分析中，我们首先计算了在极低、低、中、高和极高容量医院接受手术患者的预期寿命。然后我们探讨了各种区域化策略的影响。
所有三种癌症的预期寿命均随着医院容量的增加而稳步提高。胰腺癌切除术后的预期寿命与医院容量呈线性增加：从极低容量中心的1.9年增加到极高容量中心的3.6年。对于肺癌，预期寿命在5.4至6.6年之间。结肠癌预期寿命的增加没有那么显著：从极低容量医院的6.8年增加到极高容量医院的7.4年。不同容量分层之间预期寿命的差异主要归因于长期生存的差异，而非手术死亡率。从政策角度来看，将结肠癌手术区域化将带来最大的总体预期寿命增益，但这需要转移大多数患者。
65岁及以上的胰腺癌、肺癌和结肠癌患者在高容量医院进行癌症切除术后的预期寿命显著更长。需要进一步开展工作来了解不同医院在癌症治疗中表现差异的潜在机制。
