美国高风险手术后并发症发生率的差异。

Variation in postoperative complication rates after high-risk surgery in the United States.

作者信息

Dimick Justin B, Pronovost Peter J, Cowan John A, Lipsett Pamela A, Stanley James C, Upchurch Gilbert R

机构信息

Department of Surgery, University of Michigan Medical School, Taubman Center 2210, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0329, USA.

出版信息

Surgery. 2003 Oct;134(4):534-40; discussion 540-1. doi: 10.1016/s0039-6060(03)00273-3.

DOI:10.1016/s0039-6060(03)00273-3

PMID:14605612

Abstract

OBJECTIVE

Our goal was to characterize variation in complication rates across hospitals with differing volumes for select high-risk operations in the United States.

METHODS

Data from the Nationwide Inpatient Sample for 1996 and 1997 were analyzed for 3 high-risk operations: esophagectomy (n=1,226), pancreatectomy (n=4,789), and intact abdominal aortic aneurysm repair (n=11,863). Complications evaluated included aspiration, cardiac complications, infection, pneumonia, pulmonary failure, renal failure, septicemia, and others. The risk of complications was calculated by hospital volume deciles, as well as for high-volume hospitals (HVH) and low-volume hospitals (LVH) defined by median hospital volume.

RESULTS

Rates of any postoperative complication varied nearly 2-fold across hospital volume groups. The proportion of patients across hospital deciles having at least one complication ranged from 30% to 51% for esophageal resection, 6% to 12% for pancreatic resection, and 9% to 18% for abdominal aortic aneurysm repair. HVH had lower rates of one or more complications after pancreatic resection (OR, 0.71; 95% CI, 0.57 to 0.83; P=.002), esophageal resection (OR, 0.68; 95% CI, 0.52 to 0.90; P=.008), and intact abdominal aortic aneurysm (AAA) repair (OR, 0.67; 95% CI, 0.59 to 0.76; P<.001). Patients with one or more complications after pancreatic resection had a mortality of 18.8% versus only 5.2% for those without complications (P<.001). Esophageal resection mortality was 16.9% for patients with at least one complication and 2.5% for those without complications (P<.001) and AAA repair mortality was 10.4% for patients with at least one complication and 2.9% for those without complications (P<.001).

CONCLUSIONS

High-risk operations have a decreased rate of postoperative complications when performed at HVH. Variation in complication rates may contribute to the volume-outcome relationship and provide a focus for quality improvement at LVH.

摘要

目的

我们的目标是描述美国不同手术量医院在特定高风险手术中并发症发生率的差异。

方法

分析了1996年和1997年全国住院患者样本中3种高风险手术的数据：食管切除术（n = 1226）、胰腺切除术（n = 4789）和完整腹主动脉瘤修复术（n = 11863）。评估的并发症包括误吸、心脏并发症、感染、肺炎、呼吸衰竭、肾衰竭、败血症等。并发症风险按医院手术量十分位数计算，以及按医院中位手术量定义的高手术量医院（HVH）和低手术量医院（LVH）计算。

结果

各医院手术量组术后任何并发症的发生率相差近2倍。食管切除术患者中，各手术量十分位数组至少发生一种并发症的比例在30%至51%之间，胰腺切除术为6%至12%，腹主动脉瘤修复术为9%至18%。高手术量医院在胰腺切除术后发生一种或多种并发症的发生率较低（OR = 0.71；95% CI，0.57至0.83；P = 0.002），食管切除术后（OR = 0.68；95% CI，0.52至0.90；P = 0.008），以及完整腹主动脉瘤（AAA）修复术后（OR = 0.67；95% CI，0.59至0.76；P < 0.001）。胰腺切除术后发生一种或多种并发症的患者死亡率为18.8%，而无并发症患者仅为5.2%（P < 0.001）。食管切除术后至少发生一种并发症的患者死亡率为16.9%，无并发症患者为2.5%（P < 0.001），AAA修复术后至少发生一种并发症的患者死亡率为10.4%，无并发症患者为2.9%（P < 0.001）。