Callahan Mark A, Christos Paul J, Gold Heather T, Mushlin Alvin I, Daly John M
Department of Public Health, Weill Medical College of Cornell University and New York Presbyterian Hospital, New York, NY 10021, USA.
Ann Surg. 2003 Oct;238(4):629-36; discussion 636-9. doi: 10.1097/01.sla.0000089855.96280.4a.
This study examined the relationship of surgeon subspecialty training and interests to in-hospital mortality while controlling for both hospital and surgeon volume.
The relationship between volume of surgical procedures and in-hospital mortality has been studied and shows an inverse relationship.
A large Statewide Planning and Research Cooperative System was used to identify all 55,016 inpatients who underwent gastrectomy (n = 6434) or colectomy (n = 48,582) between January 1, 1998 and December 31, 2001. Surgical subspecialty training and interest was defined as surgeons who were members of the Society of Surgical Oncology (training/interest; n = 68) or the Society of Colorectal Surgery (training; n = 61) during the study period. The association of in-hospital mortality and subspecialty training/interest was examined using a logistic regression model, adjusting for demographics, comorbidities, insurance status, and hospital and surgeon volume.
Overall mortality for colectomy patients was 4.6%; the adjusted mortality rate for subspecialty versus nonsubspecialty-trained surgeons was 2.4% versus 4.8%, respectively (adjusted odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.34, 0.60; P < 0.0001). Gastrectomy patients experienced an overall mortality rate of 8.4%; the adjusted mortality rate for patients treated by subspecialty trained surgeons was 6.5%, while the adjusted mortality rate for nonsubspecialty trained surgeons was 8.7% (adjusted OR = 0.70; 95% CI = 0.46, 1.08; P = 0.10).
For gastrectomies and colectomies, risk-adjusted mortality is substantially lower when performed by subspecialty interested and trained surgeons, even after accounting for hospital and surgeon volume and patient characteristics. These findings may have implications for surgical training programs and for regionalization of complex surgical procedures.
本研究在控制医院规模和外科医生手术量的同时，探讨外科医生亚专业培训及兴趣与住院死亡率之间的关系。
手术量与住院死亡率之间的关系已得到研究，呈现出负相关。
利用一个大型全州规划与研究合作系统，识别出1998年1月1日至2001年12月31日期间接受胃切除术（n = 6434）或结肠切除术（n = 48,582）的所有55,016例住院患者。外科亚专业培训及兴趣定义为在研究期间属于外科肿瘤学会（培训/兴趣；n = 68）或结肠直肠外科学会（培训；n = 61）的外科医生。使用逻辑回归模型检验住院死亡率与亚专业培训/兴趣之间的关联，并对人口统计学、合并症、保险状况以及医院和外科医生手术量进行调整。
结肠切除术患者的总体死亡率为4.6%；接受亚专业培训与未接受亚专业培训的外科医生的调整后死亡率分别为2.4%和4.8%（调整后的优势比[OR] = 0.45；95%置信区间[CI] = 0.34, 0.60；P < 0.0001）。胃切除术患者的总体死亡率为8.4%；接受亚专业培训的外科医生治疗的患者调整后死亡率为6.5%，而未接受亚专业培训的外科医生调整后死亡率为8.7%（调整后的OR = 0.70；95% CI = 0.46, 1.08；P = 0.10）。
对于胃切除术和结肠切除术，即使在考虑医院和外科医生手术量以及患者特征之后，由有亚专业兴趣且经过培训的外科医生进行手术时，风险调整后的死亡率仍显著更低。这些发现可能对外科培训项目以及复杂手术的区域化具有启示意义。
