Meguid Robert A, Brooke Benjamin S, Perler Bruce A, Freischlag Julie A
Division of Vascular Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
J Vasc Surg. 2009 Aug;50(2):243-50. doi: 10.1016/j.jvs.2009.01.046. Epub 2009 May 15.
Controversy exists over the optimal hospital type to which high-risk surgical patients should be referred for operative management. While high volume centers have been traditionally advocated, recent evidence suggests teaching hospitals may have better outcomes for high-risk patients. We investigated whether mortality outcomes of patients undergoing surgery for ruptured abdominal aortic aneurysm (rAAA) were different between teaching hospitals and non-teaching hospitals, independent of hospital operative volume.
A retrospective review of the Nationwide Inpatient Sample dataset (1998-2004) was performed to identify open and endovascular (EVAR) repair for rAAA. Hospitals were stratified by teaching status, including teaching hospitals (TH) with any type of residency training program, those with general surgery training programs (GSTH) and those with vascular surgery training programs (VSTH). The association of hospital teaching status with in-hospital mortality for open AAA repair and EVAR was assessed via multi-level multivariable logistic regression, controlling for patient demographics, comorbidities, and hospital operative volume.
Of 6636 open AAA repairs for rAAA, the overall perioperative mortality was 42%. Mortality was significantly lower at TH than non-TH (39.3% vs 44.5%; P < .05). Mortality was also lower at GSTH (38.7%) and VSTH (34.3%). After adjusting for hospital operative volume, patient demographics, and comorbidities, we found a 25% decrease in likelihood of in-hospital death at VSTH vs non-VSTH (odds ratio 0.75; 95% confidence interval 0.60-0.94; P < .05).
In-hospital mortality is significantly reduced for patients undergoing open AAA repair for rAAA at teaching hospitals and hospitals with vascular surgery training programs, independent of volume. These results suggest that in addition to factors associated with teaching hospitals in general, the type of specialty training within teaching institutions is a critical factor which may influence outcomes, specifically for patients with rAAA.
对于高危手术患者应被转诊至何种最佳类型的医院进行手术治疗，目前仍存在争议。传统上一直提倡选择手术量大的中心，但最近有证据表明，教学医院对于高危患者可能会有更好的治疗效果。我们调查了教学医院和非教学医院中接受腹主动脉瘤破裂（rAAA）手术患者的死亡率是否存在差异，且不受医院手术量的影响。
对全国住院患者样本数据集（1998 - 2004年）进行回顾性分析，以确定rAAA的开放手术和血管腔内修复术（EVAR）。医院按教学状态分层，包括设有任何类型住院医师培训项目的教学医院（TH）、设有普通外科培训项目的医院（GSTH）和设有血管外科培训项目的医院（VSTH）。通过多水平多变量逻辑回归评估医院教学状态与rAAA开放手术修复和EVAR的院内死亡率之间的关联，同时控制患者人口统计学特征、合并症和医院手术量。
在6636例接受rAAA开放手术修复的患者中，围手术期总体死亡率为42%。教学医院的死亡率显著低于非教学医院（39.3%对44.5%；P < 0.05）。GSTH（38.7%）和VSTH（34.3%）的死亡率也较低。在对医院手术量、患者人口统计学特征和合并症进行调整后，我们发现VSTH与非VSTH相比，院内死亡可能性降低了25%（比值比0.75；95%置信区间0.60 - 0.94；P < 0.05）。
对于接受rAAA开放手术修复的患者，教学医院和设有血管外科培训项目的医院的院内死亡率显著降低，且不受手术量影响。这些结果表明，除了与教学医院总体相关的因素外，教学机构内的专科培训类型是一个关键因素，可能会影响治疗效果，特别是对于rAAA患者。
