Solomon Daniel H, Chibnik Lori B, Losina Elena, Huang Jenny, Fossel Anne H, Husni Elaine, Katz Jeffrey N
Division of Pharmacoepidemiology, Brigham and Women's Hospital, Boston, Massachusetts 02120, USA.
Arthritis Rheum. 2006 May;54(5):1536-42. doi: 10.1002/art.21772.
We undertook this study to assess the relationships between hospital characteristics, volume of procedures, and perioperative outcomes after total knee replacement (TKR), and to use this information to construct a simple predictive index for perioperative outcomes that incorporates hospital- and patient-level characteristics.
We studied Medicare beneficiaries who underwent TKR in 4 US states in 2000. Orthopedic surgery administrators from hospitals caring for patients in this sample were surveyed about a range of hospital characteristics. The relationships between these hospital characteristics, patient variables, and 90-day postoperative adverse events (including death, pulmonary embolus, pneumonia, deep wound infection, and acute myocardial infarction) were assessed using generalized estimating equations adjusting for hospital volume. These relationships were assessed in low- and high-risk patient groups. Variables from the final multivariate model were used to create an index that was tested against 90-day adverse event rates.
Three hundred twenty-seven (3.6%) of the patients undergoing TKR in our sample experienced an adverse event. In the final multivariate regression models, variables that predicted adverse perioperative events included low hospital volume (fewer than 23 TKRs in the Medicare population per year), absence of a preoperative teaching program, fewer TKRs conducted in a dedicated orthopedic surgery operating room, patient age >70 years, male sex, and at least 1 comorbid condition. The effect of volume on perioperative adverse events was evident both in patients with few risk factors and in patients with several risk factors. An index including the 6 patient and hospital variables discriminated well, with adverse events occurring in 2.0% (95% confidence interval [95% CI] 1.4-2.7%) of patients in the lowest risk category and in 7.4% (95% CI 4.5-12.3%) of patients in the highest risk category (P for trend < 0.001). The index predicted adverse event rates both in hospitals with a low volume of TKRs and in those with a high volume of TKRs.
Characteristics of hospital care, procedure volume, and patient-level factors are all associated with perioperative outcomes of TKR. A preliminary index combining hospital characteristics and volume is moderately predictive of adverse perioperative outcomes. The index is predictive of outcome in low- and high-volume hospitals.
我们开展这项研究以评估全膝关节置换术（TKR）后医院特征、手术量与围手术期结局之间的关系，并利用这些信息构建一个纳入医院和患者层面特征的围手术期结局简单预测指数。
我们研究了2000年在美国4个州接受TKR的医疗保险受益人。对为本样本中患者提供护理的医院的骨科手术管理人员进行了一系列医院特征方面的调查。使用广义估计方程并对医院手术量进行调整，评估这些医院特征、患者变量与术后90天不良事件（包括死亡、肺栓塞、肺炎、深部伤口感染和急性心肌梗死）之间的关系。在低风险和高风险患者组中评估了这些关系。最终多变量模型中的变量用于创建一个指数，并针对90天不良事件发生率进行检验。
我们样本中接受TKR的患者有327例（3.6%）发生了不良事件。在最终的多变量回归模型中，预测围手术期不良事件的变量包括医院手术量低（医疗保险人群中每年TKR手术少于23例）、没有术前教学计划、在专门的骨科手术手术室进行的TKR手术较少、患者年龄>70岁、男性以及至少有一种合并症。手术量对围手术期不良事件的影响在危险因素少的患者和有多种危险因素的患者中均很明显。一个包含6个患者和医院变量的指数具有良好的区分度，风险最低类别患者中不良事件发生率为2.0%（95%置信区间[95%CI]1.4 - 2.7%），风险最高类别患者中为7.4%（95%CI 4.5 - 12.3%）（趋势P<0.001）。该指数在TKR手术量低的医院和手术量高的医院中均能预测不良事件发生率。
医院护理特征、手术量和患者层面因素均与TKR的围手术期结局相关。一个结合医院特征和手术量的初步指数对围手术期不良结局有一定的预测性。该指数在手术量低和高的医院中均能预测结局。
