Dueck Andrew D, Kucey Daryl S, Johnston K Wayne, Alter David, Laupacis Andreas
Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
J Vasc Surg. 2004 Jun;39(6):1253-60. doi: 10.1016/j.jvs.2004.02.006.
The purpose of this study was to determine the effects of patient, surgeon, and hospital factors on survival after repair of ruptured abdominal aortic aneurysm (AAA) and to compare them with risk factors for survival after elective AAA repair. It was hypothesized that patients operated on by high-volume surgeons with subspecialty training would have better outcomes, which might argue for regionalization of AAA surgery.
In this population-based retrospective cohort study, surgeon billing and administrative data were used to identify all patients who had undergone AAA repair between April 1, 1992, and March 31, 2001, in Ontario, Canada. Demographic information was collected for each patient, as well as numerous variables related to the surgeons and hospitals.
There were 2601 patients with ruptured AAA repair, with an average 30-day mortality rate of 40.8%. Significant independent predictors of lower survival were older age, female gender, lower patient income quintile, performance of surgery at night or on weekends, repair in larger cities, surgeons with lower annual volume of ruptured AAA operations, and surgeons without vascular or cardiothoracic fellowship training. There were 13,701 patients with elective AAA repair, with an average 30-day mortality rate of 4.5%. Significant independent predictors of lower survival were similar, except gender was not significant, but the Charlson Comorbidity Index was. When the hazard ratios associated with predictive factors were compared, surgeon factors appeared to be more important in ruptured AAA repair, and patient factors appeared more important in elective AAA repair.
For elective AAA repair, and even more so for ruptured AAA repair, high-volume surgeons with subspecialty training conferred a significant survival benefit for patients. Although this would seem to argue in favor of regionalization, decisions should await a more complete understanding of the relationship between transfer time, delay in treatment, and outcome.
本研究旨在确定患者、外科医生和医院因素对破裂腹主动脉瘤（AAA）修复术后生存的影响，并将其与择期AAA修复术后生存的危险因素进行比较。研究假设是，由接受过亚专业培训的高手术量外科医生进行手术的患者会有更好的预后，这可能支持AAA手术的区域化。
在这项基于人群的回顾性队列研究中，利用外科医生计费和行政数据识别1992年4月1日至2001年3月31日期间在加拿大安大略省接受AAA修复的所有患者。收集了每位患者的人口统计学信息，以及与外科医生和医院相关的众多变量。
有2601例患者接受了破裂AAA修复，平均30天死亡率为40.8%。生存较低的显著独立预测因素包括年龄较大、女性、患者收入五分位数较低、在夜间或周末进行手术、在大城市进行修复、破裂AAA手术年手术量较低的外科医生以及没有血管或心胸外科专科培训的外科医生。有13701例患者接受了择期AAA修复，平均30天死亡率为4.5%。生存较低的显著独立预测因素相似，除性别不显著外，但Charlson合并症指数显著。当比较与预测因素相关的风险比时，外科医生因素在破裂AAA修复中似乎更重要，而患者因素在择期AAA修复中似乎更重要。
对于择期AAA修复，甚至对于破裂AAA修复，接受过亚专业培训的高手术量外科医生为患者带来了显著的生存益处。尽管这似乎支持区域化，但在对转运时间、治疗延迟和结果之间的关系有更全面的了解之前，不应做出决策。
