Brooke Benjamin S, Perler Bruce A, Dominici Francesca, Makary Martin A, Pronovost Peter J
Department of Surgery, Division of Vascular Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
J Vasc Surg. 2008 Jun;47(6):1155-6; discussion 1163-4. doi: 10.1016/j.jvs.2008.01.021.
The Leapfrog Group established evidence-based standards for abdominal aortic aneurysm (AAA) repair, including targets for case volume and perioperative beta-blocker usage. The purpose of this study was to determine whether meeting these benchmarks correlated with improved patient outcomes over time.
We studied California hospitals that responded to consecutive Leapfrog Group Hospital Quality and Safety Surveys between 2000 and 2005. Survey results of compliance with Leapfrog standards were linked to patient outcomes for AAA repair using the California state discharge database for the corresponding years. A random-effects Poisson regression analysis was performed to measure the effect of meeting beta-blocker and case volume standards on hospital mortality and average length of stay after elective open and endovascular AAA repair (EVAR) during the early (2000-2002) and later (2003-2005) phase of Leapfrog implementation.
Among 140 hospitals that performed open AAA repair, 25 (17.4%) met the Leapfrog case volume standard, 32 (22.2%) were compliant with routine perioperative beta-blocker use, 5 hospitals (3.5%) met both criteria, and 78 control hospitals failed to meet either standard. After controlling for temporal differences in hospital and patient characteristics, hospitals that implemented a policy for perioperative beta-blocker usage were found to have an estimated 51% reduction of in-hospital mortality (relative risk, 0.49; 95% confidence interval, 0.24-0.99; P < .05) after open AAA repair cases compared with control hospitals over time. There was no improvement in mortality outcomes over time, however, after open AAA repair in hospitals meeting case volume standards. Among 111 California hospitals in which EVAR was performed, there was an estimated 61% reduction of in-hospital mortality over time (relative risk, 0.39; 95% confidence interval, 0.07-1.80) among hospitals meeting Leapfrog case volume standards compared with control hospitals, although these results did not reach statistical significance. Finally, there was no reduction in length of hospital stay over time after either EVAR or open AAA repair for hospitals meeting Leapfrog standards compared with control hospitals.
This population-based study supports the effectiveness of meeting Leapfrog AAA repair standards towards improving mortality outcomes over time and suggests that their impact depends upon procedure type. Further studies are needed to help promote the standardization of evidence-based measures that may improve vascular surgery outcomes.
“跨越组织”制定了腹主动脉瘤（AAA）修复的循证标准，包括病例数量目标和围手术期β受体阻滞剂的使用。本研究的目的是确定随着时间推移，达到这些基准是否与改善患者预后相关。
我们研究了2000年至2005年间连续回复“跨越组织”医院质量与安全调查的加利福尼亚州医院。使用相应年份的加利福尼亚州出院数据库，将符合“跨越组织”标准的调查结果与AAA修复的患者预后相关联。进行随机效应泊松回归分析，以衡量在“跨越组织”实施的早期（2000 - 2002年）和后期（2003 - 2005年），达到β受体阻滞剂和病例数量标准对择期开放和血管腔内AAA修复（EVAR）术后医院死亡率和平均住院时间的影响。
在140家进行开放AAA修复的医院中，25家（17.4%）达到了“跨越组织”的病例数量标准，32家（22.2%）符合围手术期常规使用β受体阻滞剂的要求，5家医院（3.5%）两项标准均达到，78家对照医院两项标准均未达到。在控制了医院和患者特征的时间差异后，发现随着时间推移，与对照医院相比，实施围手术期β受体阻滞剂使用政策的医院在开放AAA修复病例后，住院死亡率估计降低了51%（相对风险，0.49；95%置信区间，0.24 - 0.99；P <.05）。然而，在达到病例数量标准的医院进行开放AAA修复后，随着时间推移死亡率结果并无改善。在111家进行EVAR的加利福尼亚州医院中，与对照医院相比，达到“跨越组织”病例数量标准的医院随着时间推移住院死亡率估计降低了61%（相对风险，0.39；95%置信区间，0.07 - 1.80），尽管这些结果未达到统计学显著性。最后，与对照医院相比，达到“跨越组织”标准的医院在EVAR或开放AAA修复后，随着时间推移住院时间并未缩短。
这项基于人群的研究支持了随着时间推移达到“跨越组织”AAA修复标准对改善死亡率结果的有效性，并表明其影响取决于手术类型。需要进一步研究以促进可能改善血管外科手术结果的循证措施的标准化。
