Nelson Caleb P, Dunn Rodney L, Wei John T, Gearhart John P
Brady Urological Institute, Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
J Urol. 2005 Sep;174(3):1099-102. doi: 10.1097/01.ju.0000169132.14799.33.
Bladder exstrophy is a rare condition, and data are lacking regarding practice patterns in its surgical management. We used a large nationwide database to investigate practice patterns of bladder exstrophy repair.
We used the Nationwide Inpatient Sample (1988 to 2000) to identify patients who underwent surgical repair of bladder exstrophy (International Classification of Disease-9 code 578.6). We analyzed factors affecting practice patterns and outcomes. Hospital volume was based on caseload during the highest volume year of study participation (high volume 5 or more, mid volume 3 to 4 and low volume less than 3 cases).
We identified 407 cases. Approximately half of the patients (53.2%) were hospitalized within 24 hours of birth, although 28% of patients were older than 1 year. Of the patients 54% were male. Exstrophy repair is extremely resource intensive. In this series mean length of hospital stay (LOS) was 24.6 +/- 22.8 days, and mean inflation adjusted hospital charges were 62,302 dollars (median 39,978 dollars). High volume hospitals (HVHs) had lower hospital charges (37,370 dollars) than mid volume (51,778 dollars) or low volume hospitals (LVHs, 50,474 dollars, p = 0.0095). On multivariate regression HVHs had lower charges even after controlling for other significant predictors, including LOS (p <0.0001). Patients at HVHs were more likely to undergo osteotomy (p = 0.007). Six patients died after exstrophy repair (1.5%), all of whom had been born prematurely (p <0.0001). Although death was more likely at LVHs, this was due to the fact that more patients at LVHs were born prematurely (4.2% at HVHs vs 5.9% at mid volume hospitals and 11.1% at LVHs, p = 0.027).
Bladder exstrophy repair carries a high risk of morbidity and is resource intensive. Variations between high and low volume hospitals in practice patterns and case mix may contribute to observed differences in resource use, LOS and clinical outcomes.
膀胱外翻是一种罕见病症，目前缺乏其外科治疗实践模式的数据。我们使用一个大型全国性数据库来研究膀胱外翻修复的实践模式。
我们利用全国住院患者样本（1988年至2000年）来确定接受膀胱外翻手术修复的患者（国际疾病分类-9编码578.6）。我们分析了影响实践模式和结果的因素。医院规模是根据参与研究的最高年份的病例数来确定的（高规模为5例或更多，中等规模为3至4例，低规模少于3例）。
我们确定了407例病例。约一半患者（53.2%）在出生后24小时内住院，不过28%的患者年龄超过1岁。患者中54%为男性。膀胱外翻修复极其耗费资源。在本系列中，平均住院时间（LOS）为24.6±22.8天，平均经通胀调整后的住院费用为62302美元（中位数为39978美元）。高规模医院（HVHs）的住院费用（37370美元）低于中等规模医院（51778美元）或低规模医院（LVHs，50474美元，p = 0.0095）。在多变量回归分析中，即使在控制了包括住院时间在内的其他重要预测因素后，高规模医院的费用仍较低（p <0.0001）。高规模医院的患者更有可能接受截骨术（p = 0.007）。6例患者在膀胱外翻修复术后死亡（1.5%），所有死亡患者均为早产（p <0.0001）。虽然低规模医院的死亡可能性更高，但这是因为低规模医院中早产患者更多（高规模医院为4.2%，中等规模医院为5.9%，低规模医院为11.1%，p = 0.027）。
膀胱外翻修复具有较高的发病风险且耗费资源。高规模医院和低规模医院在实践模式和病例组合方面的差异可能导致在资源使用、住院时间和临床结果方面观察到的差异。
