Taub David A, Miller David C, Cowan John A, Dimick Justin B, Montie James E, Wei John T
Department of Urology, University of Michigan Medical Center, Ann Arbor, Michigan, USA.
Urology. 2004 May;63(5):862-7. doi: 10.1016/j.urology.2003.11.037.
To evaluate the volume-outcome relationship in patients undergoing nephrectomy for neoplastic disease by examining the impact of the number of cases performed on in-hospital mortality and length of stay. Surgical volume is associated with postoperative mortality for many complex procedures; however, this relationship has not been characterized for patients undergoing nephrectomy for neoplastic disease.
Using the Nationwide Inpatient Sample database, 20,765 patients who underwent nephrectomy for neoplasm from 1993 through 1997 were identified by International Classification of Disease, Ninth Revision codes. Cases were stratified into volume groups on the basis of annual nephrectomy rates: low-volume hospitals performed 1 to 14 nephrectomies per year, medium-volume hospitals performed 15 to 33 per year, and high-volume hospitals performed more than 33 per year. Unadjusted and risk-adjusted analyses were performed.
Overall mortality was 1.39%. Mortality declined as surgical volume increased. The mortality rate for low-volume hospitals was 1.60% versus 1.49% for medium-volume hospitals and 1.04% for high-volume hospitals (P = 0.017). After adjusting for case mix, high-volume hospitals had a 32% lower risk of in-hospital mortality than medium-volume hospitals (P = 0.029) and a 25% lower risk than low-volume hospitals (P = 0.094). Length of stay was not affected by hospital volume. Other independent risk factors for in-hospital mortality included age older than 65 years, chronic pulmonary disease, metastatic disease, and the urgent nature of the admission.
A greater surgical volume, age younger than 65 years, elective conditions, and less comorbidity are associated with a significantly decreased risk of in-hospital mortality after nephrectomy. These findings provide compelling evidence that hospital volume and patient characteristics have important effects on surgical outcome specific to renal neoplasms.
通过研究手术例数对住院死亡率和住院时间的影响，评估因肿瘤疾病接受肾切除术患者的手术量-预后关系。对于许多复杂手术而言，手术量与术后死亡率相关；然而，这种关系在因肿瘤疾病接受肾切除术的患者中尚未得到明确描述。
利用全国住院患者样本数据库，通过国际疾病分类第九版编码识别出1993年至1997年期间因肿瘤接受肾切除术的20765例患者。根据每年的肾切除率将病例分为不同手术量组：低手术量医院每年进行1至14例肾切除术，中等手术量医院每年进行15至33例，高手术量医院每年进行超过33例。进行了未调整和风险调整分析。
总体死亡率为1.39%。死亡率随着手术量的增加而下降。低手术量医院的死亡率为1.60%，中等手术量医院为1.49%，高手术量医院为1.04%（P = 0.017）。在对病例组合进行调整后，高手术量医院的住院死亡率风险比中等手术量医院低32%（P = 0.029），比低手术量医院低25%（P = 0.094）。住院时间不受医院手术量的影响。住院死亡率的其他独立危险因素包括年龄大于65岁、慢性肺病、转移性疾病以及入院的紧急程度。
手术量越大、年龄小于65岁、择期手术以及合并症越少，肾切除术后住院死亡率风险显著降低。这些发现提供了令人信服的证据，表明医院手术量和患者特征对肾肿瘤特定的手术结局具有重要影响。
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