Hollenbeck Brent K, Taub David A, Miller David C, Dunn Rodney L, Wei John T
Department of Urology and the Division of Clinical Research, the University of Michigan, Ann Arbor, Michigan, USA.
J Urol. 2006 Feb;175(2):670-4. doi: 10.1016/S0022-5347(05)00146-1.
Regionalization of high risk surgical procedures to larger, teaching hospitals has been suggested as a means to improve the quality of care. We determined the extent to which the regionalization of nephrectomy has occurred and describe the potential causes and implications of any observed regionalization.
The Nationwide Inpatient Sample comprises a 20% sampling of hospital discharges in the United States yearly. Patients undergoing nephrectomy for kidney cancer between 1988 and 2002 were identified using International Classification of Disease, Ninth Revision, Clinical Modification codes. Regionalization was assessed using 6 structural hospital measures, including teaching status, urban location, discharge volume, nephrectomy volume, bed capacity and for-profit status. Adjusted models were developed to identify the significance of temporal trends in each regionalization measure.
We identified 66,621 patients undergoing nephrectomy during the study period. Compared to procedures performed between 1988 and 1990 the likelihood of undergoing nephrectomy at teaching, high nephrectomy volume and high throughput (all diagnoses) hospitals increased by 2.0 (CI 1.9 to 2.2), 7.4 (CI 7.1 to 7.7) and 2.2 times (CI 2.1 to 2.2), respectively, in 2000 to 2002. Conversely nephrectomy was less likely to be performed at for-profit hospitals (OR 0.5, CI 0.5 to 0.6). Patients were more likely to undergo partial nephrectomy at teaching, high volume, high throughput, urban hospitals.
Regionalization of nephrectomy to teaching and high volume (nephrectomy and all diagnoses) hospitals is currently under way. Although the implications are not entirely clear, this study provides further evidence for the crowding of complex surgical procedures into these institutions.
将高风险外科手术集中到更大的教学医院进行，被认为是提高医疗质量的一种方式。我们确定了肾切除术区域化的发生程度，并描述了任何观察到的区域化的潜在原因及影响。
全国住院患者样本包含美国每年20%的医院出院病例。使用国际疾病分类第九版临床修订本编码，识别1988年至2002年间因肾癌接受肾切除术的患者。使用6项医院结构指标评估区域化，包括教学状况、城市位置、出院量、肾切除量、床位容量和营利状况。建立调整模型以确定每个区域化指标中时间趋势的显著性。
我们在研究期间识别出66621例接受肾切除术的患者。与1988年至1990年间进行的手术相比，2000年至2002年间在教学医院、肾切除量高的医院和高流量（所有诊断）医院接受肾切除术的可能性分别增加了2.0倍（可信区间1.9至2.2）、7.4倍（可信区间7.1至7.7）和2.2倍（可信区间2.1至2.2）。相反，在营利性医院进行肾切除术的可能性较小（比值比0.5，可信区间0.5至0.6）。患者在教学医院、大容量、高流量、城市医院更有可能接受部分肾切除术。
肾切除术目前正在向教学医院和大容量（肾切除和所有诊断）医院区域化。尽管其影响尚不完全清楚，但本研究为复杂外科手术集中于这些机构提供了进一步证据。
