Liu Jerome H, Zingmond David, Etzioni David A, O'Connell Jessica B, Maggard Melinda A, Livingston Edward H, Liu Carson D, Ko Clifford Y
Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
Am Surg. 2003 Oct;69(10):823-8.
Between 1991 and 2000, the prevalence of obesity increased 65 per cent. As a result, increasing research is being directed at gastric bypass (GB) surgery, an operation that appears to achieve long-term weight reduction. Despite the rapid proliferation of this surgery, the quality of care at a population level is largely unknown. This study examines longitudinal trends in quality and identifies significant predictors of adverse outcomes. Using the California inpatient discharge database, all GB operations from 1996 to 2000 were identified. Demographic, comorbidity, complication, and volume data were obtained. Complications were defined as life-threatening cardiac, respiratory, or medical (renal failure or shock) events. Comorbidity was graded on a modified Charlson score. Annual hospital volume was categorized into four groups: < 50, 50-99, 100-199, and 200+ cases. Based on these data, we calculated longitudinal trends in complication rate and performed logistic regression to identify predictors of complications. A total of 16,232 patients were included. The average age was 41 years; 84 per cent were female, and 83.5 per cent were white. The complication rate was 10.4 per cent. Between 1996 and 2000, rates of cardiac and respiratory complications decreased while rates of medical complications remained unchanged. Complications were more likely in men [odd ratio (OR) = 1.69 compared to women] and in patients with comorbidities (OR = 1.60 for each additional comorbid disease). Furthermore, when examining the effect of volume, patients at very low (< 50) and low (50-99) volume hospitals were much more likely to have complications (OR = 2.72 and 2.70, respectively) compared to patients at high-volume hospitals (200+), even after controlling for differences in case-mix. The quality of care for obesity surgery has improved between 1996 and 2000. Despite operating on patients with more comorbidity, rates of cardiac and respiratory complications have decreased. Furthermore, this study identifies three independent predictors of complications: gender, comorbidity, and hospital volume. These findings are important initial steps toward improving quality in obesity surgery.
1991年至2000年间，肥胖症患病率上升了65%。因此，越来越多的研究聚焦于胃旁路（GB）手术，这是一种似乎能实现长期减重的手术。尽管该手术迅速普及，但总体医疗质量在很大程度上仍不为人知。本研究考察了质量的纵向趋势，并确定了不良后果的重要预测因素。利用加利福尼亚州住院患者出院数据库，识别出了1996年至2000年期间所有的胃旁路手术病例。获取了人口统计学、合并症、并发症及手术量数据。并发症定义为危及生命的心脏、呼吸或内科（肾衰竭或休克）事件。合并症根据改良的查尔森评分进行分级。年度医院手术量分为四组：<50例、50 - 99例、100 - 199例和200例以上。基于这些数据，我们计算了并发症发生率的纵向趋势，并进行逻辑回归以确定并发症的预测因素。共纳入16232例患者。平均年龄为41岁；84%为女性，83.5%为白人。并发症发生率为10.4%。1996年至2000年间，心脏和呼吸并发症发生率下降，而内科并发症发生率保持不变。男性发生并发症的可能性更大（与女性相比，比值比（OR）=1.69），合并症患者也是如此（每增加一种合并症，OR =1.60）。此外，在考察手术量的影响时，与高手术量医院（200例以上）的患者相比，极低手术量（<50例）和低手术量（50 - 99例）医院的患者发生并发症的可能性要高得多（分别为OR =2.72和2.70），即使在控制了病例组合差异之后也是如此。1996年至2000年间，肥胖症手术的医疗质量有所改善。尽管手术对象的合并症更多，但心脏和呼吸并发症发生率有所下降。此外，本研究确定了并发症的三个独立预测因素：性别、合并症和医院手术量。这些发现是朝着提高肥胖症手术质量迈出的重要的第一步。
