Judge Andy, Chard Jiri, Learmonth Ian, Dieppe Paul
MRC Health Services Research Collaboration, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK.
J Public Health (Oxf). 2006 Jun;28(2):116-24. doi: 10.1093/pubmed/fdl003. Epub 2006 Apr 5.
Previous work from other countries has shown a significant inverse relationship between the number of some surgical procedures undertaken in a hospital and in an adverse outcomes. In the light of the changing nature of the provision of joint replacements in the United Kingdom, we have examined the effects of surgical volumes and the presence/absence of training centre status, on outcomes following total joint replacement (TJR) in England.
Analysis of the Hospital Episode Statistics (HES) on all hip/knee joint replacements in English National Health Service (NHS) trusts between financial years 1997 and 2002. Exposures explored were the volume of hip/knee replacements per annum in an NHS trust, training centre status and whether the admission was routine or emergency. Four surrogate measures of adverse outcome were assessed: 30-day in-hospital mortality, length of stay in hospital, readmission within a year and surgical revision within 5 years. Age and sex were controlled for as potential confounders.
Data from a total of 281 360 hip replacements and 211 099 knee replacements were examined. HES data show that the numbers of TJRs performed in low volume trusts are small and decreasing. Adverse outcomes were also uncommon. Nevertheless, significant associations between adverse outcomes and low volume units, and better outcomes in training centres, were detected. For example, the odds ratio (OR) for in-hospital death within 30 days of hip replacement in trusts doing <50 hip/replacements per annum is 1.98 [95% confidence interval (95% CI) = 1.13-3.47] compared with trusts doing 251-500 operations/annum. Similarly, surgery in non-training centres is more likely to result in mortality than that in training centres (OR = 1.25, 95% CI = 1.05-1.48). The examination of surgical revision indicated adverse outcomes in higher volume units; this may be due to case-mix.
In England, there are fewer adverse events following TJR in high volume centres and in orthopaedic training centres. Standardization of procedures may account for this finding. The data have implications for private practice in the United Kingdom and for the current move to undertake TJRs in Independent Sector Treatment Centres.
其他国家之前的研究表明，医院进行的某些外科手术数量与不良后果之间存在显著的负相关关系。鉴于英国关节置换服务性质的变化，我们研究了手术量以及是否为培训中心对英格兰全关节置换（TJR）术后结局的影响。
对1997财年至2002财年期间英国国家医疗服务体系（NHS）信托机构中所有髋关节/膝关节置换手术的医院事件统计数据（HES）进行分析。研究的暴露因素包括NHS信托机构每年的髋关节/膝关节置换手术量、培训中心状态以及入院是常规还是急诊。评估了四种不良结局的替代指标：30天内住院死亡率、住院时间、一年内再入院率以及5年内手术翻修率。将年龄和性别作为潜在混杂因素进行控制。
共检查了281360例髋关节置换手术和211099例膝关节置换手术的数据。HES数据显示，手术量低的信托机构进行的TJR数量较少且呈下降趋势。不良结局也不常见。然而，检测到不良结局与手术量低的单位之间存在显著关联，且培训中心的结局更好。例如，与每年进行251 - 500例手术的信托机构相比，每年进行髋关节置换手术少于50例的信托机构在术后30天内的住院死亡率的比值比（OR）为1.98 [95%置信区间（95%CI）= 1.13 - 3.47]。同样，在非培训中心进行手术比在培训中心更易导致死亡（OR = 1.25，95%CI = 1.05 - 1.48）。对手术翻修的检查表明，手术量高的单位存在不良结局；这可能归因于病例组合。
在英格兰，手术量高的中心和骨科培训中心进行TJR后的不良事件较少。手术操作的标准化可能解释了这一发现。这些数据对英国的私人执业以及目前在独立部门治疗中心进行TJR的举措具有启示意义。
