Peterson Eric D, Coombs Laura P, DeLong Elizabeth R, Haan Constance K, Ferguson T Bruce
Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, NC 27715, USA.
JAMA. 2004 Jan 14;291(2):195-201. doi: 10.1001/jama.291.2.195.
There have been recent calls for using hospital procedural volume as a quality indicator for coronary artery bypass graft (CABG) surgery, but further research into analysis and policy implication is needed before hospital procedural volume is accepted as a standard quality metric.
To examine the contemporary association between hospital CABG procedure volume and outcome in a large national clinical database.
DESIGN, SETTING, AND PARTICIPANTS: Observational analysis of 267 089 isolated CABG procedures performed at 439 US hospitals participating in the Society of Thoracic Surgeons National Cardiac Database between January 1, 2000, and December 31, 2001.
Association between hospital CABG procedural volume and all-cause operative mortality (in-hospital or 30-day, whichever was longer).
The median (interquartile range) annual hospital-isolated CABG volume was 253 (165-417) procedures, with 82% of centers performing fewer than 500 procedures per year. The overall operative mortality was 2.66%. After adjusting for patient risk and clustering effects, rates of operative mortality decreased with increasing hospital CABG volume (0.07% for every 100 additional CABG procedures; adjusted odds ratio [OR], 0.98; 95% confidence interval [CI], 0.96-0.99; P =.004). While the association between volume and outcome was statistically significant overall, this association was not observed in patients younger than 65 years or in those at low operative risk and was confounded by surgeon volume. The ability of hospital volume to discriminate those centers with significantly better or worse mortality was limited due to the wide variability in risk-adjusted mortality among hospitals with similar volume. Closure of up to 100 of the lowest-volume centers (ie, those performing < or =150 CABG procedures/year) was estimated to avert fewer than 50 of 7110 (<1% of total) CABG-related deaths.
In contemporary practice, hospital procedural volume is only modestly associated with CABG outcomes and therefore may not be an adequate quality metric for CABG surgery.
近期有人呼吁将医院手术量作为冠状动脉搭桥术（CABG）手术的质量指标，但在医院手术量被接受为标准质量指标之前，需要对其分析及政策影响进行进一步研究。
在一个大型国家临床数据库中研究当代医院CABG手术量与手术结果之间的关联。
设计、设置和参与者：对2000年1月1日至2001年12月31日期间在美国胸外科医师协会国家心脏数据库中参与的439家医院进行的267089例单纯CABG手术进行观察性分析。
医院CABG手术量与全因手术死亡率（住院期间或30天，以较长者为准）之间的关联。
医院每年单纯CABG手术量的中位数（四分位间距）为253例（165 - 417例），82%的中心每年进行的手术少于500例。总体手术死亡率为2.66%。在调整患者风险和聚类效应后，手术死亡率随着医院CABG手术量的增加而降低（每增加100例CABG手术，死亡率降低0.07%；调整后的比值比[OR]为0.98；95%置信区间[CI]为0.96 - 0.99；P = 0.004）。虽然手术量与手术结果之间的关联总体上具有统计学意义，但在65岁以下患者或手术风险较低的患者中未观察到这种关联，并且受到外科医生手术量的混淆。由于手术量相似的医院之间风险调整后的死亡率差异很大，医院手术量区分死亡率明显较好或较差的中心的能力有限。估计关闭多达100个手术量最低的中心（即每年进行≤150例CABG手术的中心）可避免7110例CABG相关死亡中的不到50例（占总数的不到1%）。
在当代实践中，医院手术量与CABG手术结果仅存在适度关联，因此可能不是CABG手术的充分质量指标。
