O'Brien Maureen M, Shroyer A Laurie W, Moritz Thomas E, London Martin J, Grunwald Gary K, Villanueva Catherine B, Thottapurathu Lizy G, MaWhinney Samantha, Marshall Guillermo, McCarthy Martin, Henderson William G, Sethi Gulshan K, Grover Frederick L, Hammermeister Karl E
Medical Research Service, Denver VA Medical Center, Denver, CO 80220, USA.
Med Care. 2004 Jan;42(1):59-70. doi: 10.1097/01.mlr.0000102295.08379.57.
Information is limited regarding the effects of processes of care on cardiac surgical outcomes. Correspondingly, many recommended cardiac surgical processes of care are derived from animal experiments or clinical judgment. This report from the VA Cooperative Study in Health Services, "Processes, Structures, and Outcomes of Cardiac Surgery," focuses on the relationships between 3 process groups (preoperative evaluation, intraoperative care, and supervision by senior physicians) and a composite outcome, perioperative mortality and morbidity.
Data on 734 risk, process, and structure variables were collected prospectively on 3,988 patients who underwent coronary artery bypass grafting at 14 VA medical centers between 1992 and 1996. Data reduction was accomplished by examining data completeness and variation across sites and surgeon, using previously published data and clinical judgment. We then applied multivariable logistic regression to the 39 remaining processes of care to determine which were related to the composite outcome after adjusting for 17 patient-related risk factors and controlling for intraoperative complications.
Our first analysis showed several measures of operative duration, the use of inotropic agents, transesophageal echo, lowest systemic temperature, and hemoconcentration/ultrafiltration, to be powerful predictors of the composite outcome. Because the use of inotropic agents and operative duration may be related to an intermediate outcome (eg, intraoperative complications), we performed a second analysis omitting these processes. The use of intraoperative transesophageal echo and hemoconcentration/ultrafiltration remained significantly associated with an increased risk of an event (odds ratios 1.60 and 1.36, respectively).
Our results viewed in the context of past studies suggest the possibility that inotropic use, TEE, and hemoconcentration/ultrafiltration may have adverse effects on operative outcome. Further evaluation of these processes of care using observational data, as well as randomized trials when feasible, would be of interest.
关于医疗过程对心脏外科手术结果的影响，相关信息有限。相应地，许多推荐的心脏外科医疗过程源自动物实验或临床判断。这份来自退伍军人事务部卫生服务合作研究的报告《心脏手术的过程、结构和结果》，聚焦于三个医疗过程组（术前评估、术中护理以及高级医师监督）与一个综合结果（围手术期死亡率和发病率）之间的关系。
前瞻性收集了1992年至1996年间在14家退伍军人事务部医疗中心接受冠状动脉旁路移植术的3988例患者的734个风险、过程和结构变量的数据。通过检查数据完整性以及各站点和外科医生之间的差异，并利用先前发表的数据和临床判断来完成数据简化。然后，我们对其余39个医疗过程应用多变量逻辑回归，以确定在调整了17个与患者相关的风险因素并控制术中并发症后，哪些过程与综合结果相关。
我们的首次分析表明，手术持续时间的几项指标、血管活性药物的使用、经食管超声心动图、最低体温以及血液浓缩/超滤，是综合结果的有力预测指标。由于血管活性药物的使用和手术持续时间可能与中间结果（如术中并发症）相关，我们进行了第二次分析，排除了这些过程。术中经食管超声心动图的使用和血液浓缩/超滤与事件风险增加仍显著相关（优势比分别为1.60和1.36）。
我们的结果结合以往研究来看，提示血管活性药物的使用、经食管超声心动图以及血液浓缩/超滤可能对手术结果产生不利影响。利用观察性数据对这些医疗过程进行进一步评估，以及在可行时进行随机试验，将会很有意义。
