O'Connor G T, Plume S K, Olmstead E M, Coffin L H, Morton J R, Maloney C T, Nowicki E R, Tryzelaar J F, Hernandez F, Adrian L
Department of Medicine, Dartmouth-Hitchock Medical Center, Hanover, NH 03756.
JAMA. 1991 Aug 14;266(6):803-9.
A prospective regional study was conducted to determine if the observed differences in in-hospital mortality rates associated with coronary artery bypass grafting (CABG) are solely the result of differences in patient case mix. DESIGN-Regional prospective cohort study. Data including patient demographic and historical data, body surface area, cardiac catheterization results, priority of surgery, comorbidity, and status at hospital discharge were collected. This study presents data for 3055 CABG patients between July 1, 1987, and April 15, 1989.
This study includes data from all surgeons performing cardiothoracic surgery in Maine, New Hampshire, and Vermont; the data were collected from five regional medical centers.
Data were collected from all consecutive isolated CABG surgery patients during the study period.
Crude and adjusted in-hospital mortality rates associated with CABG.
The overall crude in-hospital mortality rate for isolated CABG was 4.3%. The rate varied among centers (range, 3.1% to 6.3%) and among surgeons (range, 1.9% to 9.2%). Predictors of in-hospital mortality included increased age, female gender, small body surface area, greater comorbidity, reoperation, poorer cardiac function as indicated by a lower ejection fraction, increased left ventricular end diastolic pressure and emergent or urgent surgery. After adjusting for the effects of potentially confounding variables, substantial and statistically significant variability was observed among medical centers (P = .021) and among surgeons (P = .025).
We conclude that the observed differences in in-hospital mortality rates among institutions and among surgeons in northern New England are not solely the result of differences in case mix as described by these variables and may reflect differences in currently unknown aspects of patient care. Understanding this variation requires a detailed understanding of the processes of care.
开展一项前瞻性区域研究，以确定观察到的冠状动脉旁路移植术（CABG）相关住院死亡率差异是否仅由患者病例组合差异所致。设计——区域前瞻性队列研究。收集了包括患者人口统计学和病史数据、体表面积、心导管检查结果、手术优先级、合并症以及出院时状况等数据。本研究呈现了1987年7月1日至1989年4月15日期间3055例CABG患者的数据。
本研究纳入了缅因州、新罕布什尔州和佛蒙特州所有进行心胸外科手术的外科医生的数据；数据来自五个区域医疗中心。
研究期间收集了所有连续接受单纯CABG手术患者的数据。
与CABG相关的粗住院死亡率和调整后住院死亡率。
单纯CABG的总体粗住院死亡率为4.3%。该比率在各中心之间有所不同（范围为3.1%至6.3%），在外科医生之间也有所不同（范围为1.9%至9.2%）。住院死亡率的预测因素包括年龄增加、女性、体表面积小、合并症更多、再次手术、射血分数较低表明心脏功能较差、左心室舒张末期压力升高以及急诊或紧急手术。在调整了潜在混杂变量的影响后，观察到医疗中心之间（P = .021）和外科医生之间（P = .025）存在显著且具有统计学意义的差异。
我们得出结论，新英格兰北部各机构之间以及外科医生之间观察到的住院死亡率差异并非仅由这些变量所描述的病例组合差异所致，可能反映了患者护理当前未知方面的差异。理解这种差异需要详细了解护理过程。
