Ho Vivian, Heslin Martin J, Yun Huifeng, Howard Lee
Department of Economics, Baker Institute, Rice University, MS 22, 6100 Main St., Houston, Texas 77005, USA.
Ann Surg Oncol. 2006 Jun;13(6):851-8. doi: 10.1245/ASO.2006.07.021. Epub 2006 Apr 13.
We measured 13-year trends in operative mortality for six cancer resections. We then examined whether these trends are driven by changes in hospital and surgeon volume or by changes that occurred among all providers, regardless of volume.
We analyzed administrative discharge data on patients who received one of six cancer resections in Florida, New Jersey, and New York for three time periods: 1988 to 1991, 1992 to 1996, and 1997 to 2000. Descriptive statistics and nested regression models were used to test for changes in the association between inpatient mortality and annual hospital and annual surgeon volume over time, adjusting for patient and hospital characteristics.
Unadjusted inpatient mortality rates for the six cancer resections declined between .8 and 4.0 percentage points between the time periods 1988 to 1991 and 1997 to 2000. Over this time period, annual hospital and surgeon volumes for the six cancer operations increased an average of 24.3% and 24.2%, respectively. The logistic regressions indicated a relatively stable relationship over time between both increased hospital and surgeon volume and lower inpatient mortality. Simulations suggest that increases in hospital and surgeon procedure volume over time led to a reduction in inpatient mortality ranging from .1 percentage points for rectal cancer to 2.3 percentage points for pneumonectomy.
Persistence of the volume-outcome relation and increasing hospital and surgeon volumes explain much of the decline over time in inpatient mortality for five of the six cancer operations studied. Concentrating cancer resections among high-volume providers should lead to further reduced inpatient mortality.
我们测量了六种癌症切除术的13年手术死亡率趋势。然后，我们研究了这些趋势是由医院和外科医生手术量的变化驱动的，还是由所有医疗服务提供者（无论手术量如何）之间发生的变化驱动的。
我们分析了佛罗里达州、新泽西州和纽约州接受六种癌症切除术之一的患者在三个时间段（1988年至1991年、1992年至1996年、1997年至2000年）的行政出院数据。使用描述性统计和嵌套回归模型来检验住院死亡率与年度医院手术量和年度外科医生手术量之间随时间的关联变化，并对患者和医院特征进行调整。
在1988年至1991年和1997年至2000年期间，六种癌症切除术未经调整的住院死亡率下降了0.8至4.0个百分点。在此期间，六种癌症手术的年度医院手术量和外科医生手术量分别平均增加了24.3%和24.2%。逻辑回归表明，随着时间的推移，医院手术量和外科医生手术量的增加与较低的住院死亡率之间存在相对稳定的关系。模拟结果表明，随着时间的推移，医院和外科医生手术量的增加导致住院死亡率降低，范围从直肠癌的0.1个百分点到肺切除术的2.3个百分点。
手术量-结果关系的持续存在以及医院和外科医生手术量的增加，解释了所研究的六种癌症手术中五种手术住院死亡率随时间下降的大部分原因。将癌症切除术集中在高手术量的医疗服务提供者中应会进一步降低住院死亡率。
