Hollenbeck Brent K, Miller David C, Taub David A, Dunn Rodney L, Khuri Shukri F, Henderson William G, Montie James E, Underwood Willie, Wei John T
Department of Urology, University of Michigan, Ann Arbor, Michigan, USA.
J Urol. 2006 Oct;176(4 Pt 1):1363-8. doi: 10.1016/j.juro.2006.06.015.
Prior studies evaluating quality of care following radical cystectomy have been constrained by the use of retrospective reviews of single institutional series and limited ability to examine risk factors in a comprehensive manner. Characterization of these factors could enhance preoperative patient counseling and facilitate perioperative management, thereby improving the quality of patient care.
The National Surgical Quality Improvement Project is a prospective quality management initiative at 123 Veterans Affairs Medical Centers nationwide. The project collects preoperative clinical and intraoperative data, and outcomes on a wide variety of surgical procedures from multiple surgical disciplines. Since 1991, 2,538 radical cystectomies have been captured by the National Surgical Quality Improvement Project. Modeling using logistic regression was performed to identify preoperative risk factors associated with mortality and prolonged length of stay (greater than 90th percentile) after radical cystectomy.
The 30 and 90-day mortality rates following cystectomy were 2.9% and 6.8%, respectively, and median hospital stay was 11 days (90th percentile 30). Robust preoperative factors associated with mortality and prolonged length of stay that uniformly increased risk were older patient age (OR 1.2 to 1.4), American Society of Anesthesiologists class 3 or greater (OR 1.5 to 3.3), dependent functional status (OR 1.7 to 2.0) and low serum albumin (OR 2.1 to 12.0).
A defined set of preoperative risk factors is independently associated with greater mortality and hospital stay following radical cystectomy. The breadth of these factors suggests that complex case mix adjustment is mandatory when comparing outcomes. Implementation of novel processes directed toward minimizing patient risk has the potential to improve outcomes following cystectomy.
既往评估根治性膀胱切除术后护理质量的研究受到单机构系列回顾性研究的限制，且全面检查风险因素的能力有限。对这些因素的特征进行描述可加强术前患者咨询并促进围手术期管理，从而提高患者护理质量。
国家外科质量改进项目是一项在全国123家退伍军人事务医疗中心开展的前瞻性质量管理计划。该项目收集术前临床和术中数据，以及来自多个外科学科的各种手术的结果。自1991年以来，国家外科质量改进项目已记录了2538例根治性膀胱切除术。采用逻辑回归建模来确定与根治性膀胱切除术后死亡率和延长住院时间（大于第90百分位数）相关的术前风险因素。
膀胱切除术后30天和90天死亡率分别为2.9%和6.8%，中位住院时间为11天（第90百分位数为30天）。与死亡率和延长住院时间相关且风险一致增加的稳健术前因素包括患者年龄较大（比值比1.2至1.4）、美国麻醉医师协会分级为3级或更高（比值比1.5至3.3）、依赖性功能状态（比值比1.7至2.0）和低血清白蛋白（比值比2.1至12.0）。
一组明确的术前风险因素与根治性膀胱切除术后更高的死亡率和住院时间独立相关。这些因素的广度表明，在比较结果时必须进行复杂的病例组合调整。实施旨在将患者风险降至最低的新流程有可能改善膀胱切除术后的结果。
