Allen Steven W, Gauvreau Kimberlee, Bloom Barry T, Jenkins Kathy J
Pediatric Cardiology, Wichita Clinic, Wichita, Kansas 67208, USA.
Pediatrics. 2003 Jul;112(1 Pt 1):24-8. doi: 10.1542/peds.112.1.24.
Significant interinstitutional variation in mortality after congenital heart surgery has been demonstrated. Noting an association between reduced mortality and higher volume, a center with a small annual case volume began in August 1998 to selectively refer to high-volume surgical centers based on published or "apparent" low mortality rates for specific cardiac lesions. This study was undertaken to evaluate the effect of evidence-based referral in this practice.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort comparison over a 10-year period for a small Midwestern pediatric cardiology practice. The institutional database was retrospectively reviewed for children (<18 years) undergoing surgery from August 1992 to July 2002. Data were divided into 3 time periods (August 1992 to July 1995, period 1; August 1995 to July 1998, period 2; and August 1998 to July 2002, period 3). Hospital discharge abstract data from 5 states (California, Illinois, Massachusetts, Pennsylvania, and Washington) in 1992, 1996, and 1998 provided contemporaneous benchmarks. Risk adjustment was performed using the Risk Adjustment in Congenital Heart Surgery-1 method. Risk category, age at surgery, prematurity, and major noncardiac structural anomaly were entered into a multivariate logistic regression model to compare in-hospital mortality adjusting for case-mix differences.
A total of 514 congenital heart surgical cases were identified from August 1992 to July 2002; 507 cases (98.6%) were assigned to a risk category and analyzed further. Unadjusted in-hospital mortality rates were 9.3% in period 1, 5.9% in period 2, and 1.3% in period 3. Unadjusted mortality rates for cases from benchmark data were 6.4% in 1992, 4.8% in 1996, and 3.7% in 1998. Risk adjusted mortality was comparable to the benchmark data in periods 1 and 2, but superior outcomes (odds ratio = 0.24) were demonstrated in period 3.
Evidence-based referrals from a small-volume pediatric cardiac center to large-volume institutions resulted in a reduction in mortality after congenital heart surgery.
已证实先天性心脏手术后机构间死亡率存在显著差异。鉴于死亡率降低与手术量增加之间存在关联，一家年手术量较小的中心于1998年8月开始根据已发表的或“明显”的特定心脏病变低死亡率，选择性地将患者转诊至高手术量的外科中心。本研究旨在评估这种基于证据的转诊做法的效果。
设计、背景和参与者：对美国中西部一家小型儿科心脏病诊所进行为期10年的回顾性队列比较。对该机构数据库进行回顾，纳入1992年8月至2002年7月接受手术的18岁以下儿童。数据分为3个时间段（1992年8月至1995年7月，第1期；1995年8月至1998年7月，第2期；1998年8月至2002年7月，第3期）。1992年、1996年和1998年来自5个州（加利福尼亚州、伊利诺伊州、马萨诸塞州、宾夕法尼亚州和华盛顿州）的医院出院摘要数据提供了同期基准。使用先天性心脏病手术风险调整-1方法进行风险调整。将风险类别、手术时年龄、早产情况和主要非心脏结构异常纳入多因素逻辑回归模型，以比较调整病例组合差异后的住院死亡率。
1992年8月至2002年7月共识别出514例先天性心脏手术病例；507例（98.6%）被归入风险类别并进一步分析。第1期未调整的住院死亡率为9.3%，第2期为5.9%，第3期为1.3%。基准数据中病例的未调整死亡率在1992年为6.4%，1996年为4.8%，1998年为3.7%。第1期和第2期风险调整后的死亡率与基准数据相当，但第3期显示出更好的结果（优势比=0.24）。
从小规模儿科心脏中心向大规模机构进行基于证据的转诊，可降低先天性心脏手术后的死亡率。
