Cooperberg Matthew R, Modak Sanjukta, Konety Badrinath R
Urologic Outcomes Research Group, Program in Urologic Oncology, Department of Urology, University of California-San Francisco Comprehensive Cancer Center, California 94115-1711, USA.
J Urol. 2007 Nov;178(5):2103-8; discussion 2108. doi: 10.1016/j.juro.2007.07.040. Epub 2007 Sep 17.
Higher hospital and clinician volumes may be associated with improved patient outcomes for complex surgical and medical care, although the strength and consistency of this association varies markedly across specific conditions and procedures. Pressures from payors and policymakers exist to move complex care to high volume hospitals. The net effect of these pressures may be the regionalization of care. We quantified trends in the regionalization of inpatient care for urological oncology in a national administrative database.
The Nationwide Inpatient Sample, a 20% stratified sample of United States community hospital admissions, was queried for surgical and nonsurgical admissions for bladder, renal and prostate cancer care between 1988 and 2002. Hospitals were grouped into tertiles by annual surgical volume. Trends over time in the annual discharge rate by hospital volume tertile, geographic region and insurance status were analyzed.
High volume hospitals were defined by at least 22, 12 and 26 cases per year for bladder, renal and prostate cancer, respectively. High volume hospital discharges increased significantly as a proportion of all discharges for bladder (67% to 70%) and renal (67% to 73%) cancer surgery, and they were essentially constant for prostate surgery (76%). Trends were similar for Medicare and Medicaid patients except high volume hospital discharges for prostate cancer decreased during the study period. Significant regional variation was observed for the regionalization of surgical and nonsurgical care.
Nationwide Inpatient Sample data demonstrate the ongoing regionalization of urological oncology care. The policy implications of this trend are complex with potentially important benefits and risks in terms of access to and quality of care.
对于复杂的外科手术和医疗护理，医院及临床医生的业务量增加可能与患者预后改善相关，尽管这种关联的强度和一致性在不同的具体病症和手术中差异显著。支付方和政策制定者存在将复杂护理转移至高业务量医院的压力。这些压力的净效应可能是医疗服务的区域化。我们在一个全国性行政数据库中对泌尿外科肿瘤住院护理的区域化趋势进行了量化。
利用全国住院患者样本（美国社区医院入院患者的20%分层样本），查询1988年至2002年间膀胱、肾脏和前列腺癌护理的手术和非手术入院情况。医院按年度手术量分为三分位数组。分析了按医院业务量三分位数、地理区域和保险状况划分的年度出院率随时间的趋势。
高业务量医院的定义分别为每年至少有22例、12例和26例膀胱、肾脏和前列腺癌病例。高业务量医院的出院量占膀胱（从67%增至70%）和肾脏（从67%增至73%）癌手术所有出院量的比例显著增加，而前列腺手术的这一比例基本保持不变（76%）。医疗保险和医疗补助患者的趋势相似，只是研究期间前列腺癌高业务量医院的出院量有所下降。手术和非手术护理的区域化存在显著的地区差异。
全国住院患者样本数据表明泌尿外科肿瘤护理正在区域化。这一趋势的政策影响较为复杂，在医疗可及性和护理质量方面可能带来潜在的重要益处和风险。
