Barker Fred G, Curry William T, Carter Bob S
Stephen E. and Catherine Pappas Center for Neuro-Oncology, Neurosurgical Service, Massachusetts General Hospital, Department of Surgery (Neurosurgery), Harvard Medical School, Boston, MA 02114, USA.
Neuro Oncol. 2005 Jan;7(1):49-63. doi: 10.1215/S1152851704000146.
Contemporary reports of patient outcomes after biopsy or resection of primary brain tumors typically reflect results at specialized centers. Such reports may not be representative of practices in nonspecialized settings. This analysis uses a nationwide hospital discharge database to examine trends in mortality and outcome at hospital discharge in 38,028 admissions for biopsy or resection of supratentorial primary brain tumors in adults between 1988 and 2000, particularly in relation to provider caseload. Multivariate analyses showed that large-volume centers had lower in-hospital postoperative mortality rates than centers with lighter caseloads, both for craniotomies (odds ratio [OR] 0.75 for a tenfold larger caseload) and for needle (closed) biopsies (OR 0.54). Adverse discharge disposition was also less likely at high-volume hospitals, both for craniotomies (OR 0.77) and for needle biopsies (OR 0.67). The annual number of surgical admissions increased by 53% during the 12-year study period, and in-hospital mortality rates decreased during this period, from 4.8% to 1.8%. Mortality rates decreased over time, both for craniotomies and for needle biopsies. Subgroup analyses showed larger relative mortality rate reductions at large-volume centers than at small-volume centers (73% vs. 43%, respectively). The number of US hospitals performing one or more craniotomies annually for primary brain tumors decreased slightly, and the number performing needle biopsies increased. There was little change in median hospital annual craniotomy caseloads, but the largest centers had disproportionate growth in volume. The 100 highest-caseload US hospitals accounted for an estimated 30% of the total US surgical primary brain tumor caseload in 1988 and 41% in 2000. Our findings do not establish minimum volume thresholds for acceptable surgical care of primary brain tumors. However, they do suggest a trend toward progressive centralization of craniotomies for primary brain tumor toward large-volume US centers during this interval.
关于原发性脑肿瘤活检或切除术后患者预后的当代报告通常反映的是专业中心的结果。此类报告可能无法代表非专业环境中的医疗实践情况。本分析使用全国性医院出院数据库，研究了1988年至2000年间38028例成人幕上原发性脑肿瘤活检或切除住院病例的死亡率和出院时的预后趋势，尤其涉及医疗服务提供者的病例数量。多变量分析显示，大容量中心的术后住院死亡率低于病例数量较少的中心，无论是开颅手术（病例数量增加十倍时的比值比[OR]为0.75）还是针吸（闭合式）活检（OR为0.54）。高容量医院不良出院处置的可能性也较小，开颅手术（OR为0.77）和针吸活检（OR为0.67）均如此。在为期12年的研究期间，手术住院病例数每年增加53%，在此期间住院死亡率从4.8%降至1.8%。开颅手术和针吸活检的死亡率均随时间下降。亚组分析显示，大容量中心的相对死亡率下降幅度大于小容量中心（分别为73%和43%）。每年进行一例或多例原发性脑肿瘤开颅手术的美国医院数量略有减少，而进行针吸活检的医院数量增加。医院每年开颅手术病例数量的中位数变化不大，但最大的中心病例数量增长不成比例。1988年，美国病例数量最高的100家医院估计占美国原发性脑肿瘤手术病例总数的30%，2000年占41%。我们的研究结果并未确定原发性脑肿瘤可接受手术治疗的最低病例数量阈值。然而，它们确实表明在此期间，美国原发性脑肿瘤开颅手术有逐渐向大容量中心集中的趋势。
