Galandiuk Susan, Mahid Suhal S, Polk Hiram C, Turina Matthias, Rao Mohan, Lewis John N
Department of Surgery, Price Institute for Surgical Research, University of Louisville School of Medicine, Louisville, KY, USA.
Surgery. 2006 Oct;140(4):589-96. doi: 10.1016/j.surg.2006.07.010.
The importance of rural operations is magnified by super-specialization, uneven geographic distribution, and special educational needs. Definition of practice patterns and quality measures are needed.
A statewide network of 60 operative specialists studied costs, quality, and outcomes in 17,319 patients undergoing 46 different specialty operations between 1998 and 2003, comparing 9,544 rural to 7,775 urban patients. These data are augmented by additional data from 5,339 operative patients in 2004.
Both high volume rural and urban surgeons achieved fewer deaths than less frequent practitioners of colon or rectal resections (2/309 vs 5/167). Urban surgeons had sicker patients undergoing more extensive procedures, and used fewer consultations, but had more complications and reoperations. Laparoscopic cholecystectomy had similar outcomes with 5 deaths among 1,788 patients. Urban surgeons converted to an open procedure more frequently, whereas rural surgeons used hepatobiliary iminodiacetic acid (HIDA) scans as indication for cholecystectomy more often (P < .01). Indications for upper and lower endoscopy varied, but abnormalities were noted in 64%; only 11 of 6,938 patients undergoing endoscopy were admitted for complications, 5 required operations, 3 due to totally obstructing cancers. Hysterectomy, urologic procedures, and tympanostomy had admission/readmission rates as low as 1/400. Documented patient preoperative education occurred in 94% of both groups. Overall, performance measures were addressed more consistently by rural surgeons (P < .001).
Operative practice reaches high standards in both settings; indications for operations vary, and rural practice is broader than urban practice. Rural surgeons exceed their urban colleagues on some quality process measures.
超级专业化、地理分布不均以及特殊教育需求使得农村手术的重要性更为凸显。需要对手术模式和质量指标进行界定。
一个由60名手术专家组成的全州性网络研究了1998年至2003年间17319例接受46种不同专科手术患者的成本、质量和结局，将9544例农村患者与7775例城市患者进行比较。2004年5339例手术患者的额外数据对这些数据进行了补充。
高手术量的农村和城市外科医生在结肠或直肠切除术中的死亡人数均少于手术频率较低的医生（2/309对5/167）。城市外科医生的患者病情更重，接受的手术更广泛，会诊次数更少，但并发症和再次手术更多。1788例患者接受腹腔镜胆囊切除术的结局相似，有5例死亡。城市外科医生更频繁地转为开放手术，而农村外科医生更常将肝胆亚氨基二乙酸（HIDA）扫描作为胆囊切除术的指征（P <.01）。上下消化道内镜检查的指征各不相同，但64%的患者发现有异常；6938例接受内镜检查的患者中，只有11例因并发症入院，5例需要手术，其中3例是由于完全阻塞性癌症。子宫切除术、泌尿外科手术和鼓膜切开术的入院/再入院率低至1/400。两组中94%的患者都有术前教育记录。总体而言，农村外科医生在绩效指标方面的执行更为一致（P <.001）。
两种环境下的手术实践均达到了高标准；手术指征各不相同，农村的手术范围比城市更广。在一些质量过程指标方面，农村外科医生超过了他们的城市同行。
