Itani Kamal M F, DePalma Ralph G, Schifftner Tracy, Sanders Karen M, Chang Barbara K, Henderson William G, Khuri Shukri F
VA Boston Health Care System (112A), Boston and Harvard Universities, 1400 VFW Pkwy., West Roxbury, MA 02132, USA.
Am J Surg. 2005 Nov;190(5):725-31. doi: 10.1016/j.amjsurg.2005.06.042.
There has been concern that a reduced level of surgical resident supervision in the operating room (OR) is correlated with worse patient outcomes. Until September 2004, Veterans' Affairs (VA) hospitals entered in the surgical record level 3 supervision on every surgical case when the attending physician was available but not physically present in the OR or the OR suite. In this study, we assessed the impact of level 3 on risk-adjusted morbidity and mortality in the VA system.
Surgical cases entered into the National Surgical Quality Improvement Program database between 1998 and 2004, from 99 VA teaching facilities, were included in a logistic regression analysis for each year. Level 3 versus all other levels of supervision were forced into the model, and patient characteristics then were selected stepwise to arrive at a final model. Confidence limits for the odds ratios were calculated by profile likelihood.
A total of 610,660 cases were available for analysis. Thirty-day mortality and morbidity rates were reported in 14,441 (2.36%) and 63,079 (10.33%) cases, respectively. Level 3 supervision decreased from 8.72% in 1998 to 2.69% in 2004. In the logistic regression analysis, the odds ratios for mortality for level 3 ranged from .72 to 1.03. Only in the year 2000 were the odds ratio for mortality statistically significant at the .05 level (odds ratio, .72; 95% confidence interval, .594-.858). For morbidity, the odds ratios for level 3 supervision ranged from .66 to 1.01, and all odds ratios except for the year 2004 were statistically significant.
Between 1998 and 2004, the level of resident supervision in the OR did not affect clinical outcomes adversely for surgical patients in the VA teaching hospitals.
人们一直担心手术室（OR）中外科住院医师监督水平的降低与更差的患者预后相关。直到2004年9月，退伍军人事务部（VA）医院在手术记录中，当主治医生有空但未实际在手术室或手术室区域时，对每例手术记录为3级监督。在本研究中，我们评估了3级监督对VA系统中风险调整后的发病率和死亡率的影响。
1998年至2****年期间，来自99家VA教学机构并录入国家外科质量改进计划数据库的手术病例，每年纳入逻辑回归分析。将3级监督与所有其他监督级别强制纳入模型，然后逐步选择患者特征以得出最终模型。比值比的置信限通过轮廓似然法计算。
共有610,660例病例可供分析。分别有14,441例（2.36%）和63,079例（10.33%）病例报告了30天死亡率和发病率。3级监督从1998年的8.72%降至2004年的2.69%。在逻辑回归分析中，3级监督的死亡率比值比在0.72至1.03之间。仅在2000年，死亡率比值比在0.05水平具有统计学意义（比值比，0.72；95%置信区间，0.594 - 0.858）。对于发病率，3级监督的比值比在0.66至1.01之间，除2004年外所有比值比均具有统计学意义。
1998年至2004年期间，VA教学医院手术室中住院医师的监督水平并未对手术患者的临床结局产生不利影响。
