Smith Edward R, Butler William E, Barker Fred G
Massachusetts General Hospital, and Department of Surgery (Neurosurgery), Harvard Medical School, Boston, Massachusetts 02114, USA.
Neurosurgery. 2004 Mar;54(3):553-63; discussion 563-5. doi: 10.1227/01.neu.0000108421.69822.67.
Large provider caseloads are associated with better patient outcomes after many complex surgical procedures. Mortality rates for pediatric brain tumor surgery in various practice settings have not been described. We used a national hospital discharge database to study the volume-outcome relationship for craniotomy performed for pediatric brain tumor resection, as well as trends toward centralization and specialization.
We conducted a cross sectional and longitudinal cohort study using Nationwide Inpatient Sample data for 1988 to 2000 (Agency for Healthcare Research and Quality, Rockville, MD). Multivariate analyses adjusted for age, sex, geographic region, admission type (emergency, urgent, or elective), tumor location, and malignancy.
We analyzed 4712 admissions (329 hospitals, 480 identified surgeons) for pediatric brain tumor craniotomy. The in-hospital mortality rate was 1.6% and decreased from 2.7% (in 1988-1990) to 1.2% (in 1997-2000) during the study period. On a per-patient basis, median annual caseloads were 11 for hospitals (range, 1-59 cases) and 6 for surgeons (range, 1-32 cases). In multivariate analyses, the mortality rate was significantly lower at high-volume hospitals than at low-volume hospitals (odds ratio, 0.52 for 10-fold larger caseload; 95% confidence interval, 0.28-0.94; P = 0.03). The mortality rate was 2.3% at the lowest-volume-quartile hospitals (4 or fewer admissions annually), compared with 1.4% at the highest-volume-quartile hospitals (more than 20 admissions annually). There was a trend toward lower mortality rates after surgery performed by high-volume surgeons (P = 0.16). Adverse hospital discharge disposition was less likely to be associated with high-volume hospitals (P < 0.001) and high-volume surgeons (P = 0.004). Length of stay and hospital charges were minimally related to hospital caseloads. Approximately 5% of United States hospitals performed pediatric brain tumor craniotomy during this period. The burden of care shifted toward large-caseload hospitals, teaching hospitals, and surgeons whose practices included predominantly pediatric patients, indicating progressive centralization and specialization.
Mortality and adverse discharge disposition rates for pediatric brain tumor craniotomy were lower when the procedure was performed at high-volume hospitals and by high-volume surgeons in the United States, from 1988 to 2000. There were trends toward lower mortality rates, greater centralization of surgery, and more specialization among surgeons during this period.
在许多复杂外科手术中，医疗服务提供者处理的病例数量越多，患者预后越好。目前尚未描述不同医疗环境下小儿脑肿瘤手术的死亡率。我们使用全国医院出院数据库，研究小儿脑肿瘤切除开颅手术的手术量与预后的关系，以及手术集中化和专业化的趋势。
我们利用1988年至2000年的全国住院患者样本数据（医疗保健研究与质量局，马里兰州罗克维尔）进行了一项横断面和纵向队列研究。多变量分析对年龄、性别、地理区域、入院类型（急诊、 urgent或择期）、肿瘤位置和恶性程度进行了调整。
我们分析了4712例小儿脑肿瘤开颅手术的入院病例（329家医院，480名已识别的外科医生）。住院死亡率为1.6%，在研究期间从1988 - 1990年的2.7%降至1997 - 2000年的1.2%。以患者为基础，医院的年病例中位数为11例（范围为1 - 59例），外科医生为6例（范围为1 - 32例）。在多变量分析中，高手术量医院的死亡率显著低于低手术量医院（病例量增加10倍时的优势比为0.52；95%置信区间为0.28 - 0.94；P = 0.03）。手术量最低四分位数的医院（每年4例或更少入院病例）的死亡率为2.3%，而手术量最高四分位数的医院（每年超过20例入院病例）为1.4%。高手术量外科医生手术后的死亡率有降低趋势（P = 0.16）。不良出院处置与高手术量医院（P < 0.001）和高手术量外科医生（P = 0.004）的关联较小。住院时间和医院费用与医院手术量的关系最小。在此期间，约5%的美国医院进行了小儿脑肿瘤开颅手术。医疗负担向手术量大的医院、教学医院以及主要诊治小儿患者的外科医生转移，表明手术逐渐集中化和专业化。
1988年至2000年期间，在美国，小儿脑肿瘤开颅手术在高手术量医院由高手术量外科医生进行时，死亡率和不良出院处置率较低。在此期间，有死亡率降低、手术更加集中化以及外科医生更加专业化的趋势。
