Juillard Catherine, Lashoher Angela, Sewell Catherine A, Uddin Sayeedha, Griffith John G, Chang David C
Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA.
J Am Coll Surg. 2009 Apr;208(4):599-606. doi: 10.1016/j.jamcollsurg.2009.01.003.
Volume-to-outcomes relationships have been established for high-risk surgical procedures. To determine whether hospital volume and academic center status affect surgical outcomes in a lower-risk procedure, morbidity and mortality in patients undergoing abdominal hysterectomy for leiomyoma were evaluated.
Administrative data from the National Inpatient Sample were used to conduct a retrospective analysis of 172,344 individuals who had primary diagnoses of leiomyomata (ICD-9 diagnosis codes of 218.x in the first 2 positions) and who underwent abdominal hysterectomy (ICD-9 procedure codes 68.4 in the first 2 positions) from 1999 to 2003. Comparison was made between teaching hospitals versus nonteaching hospitals and annual case volume in quintiles. Morbidity was considered to be any postoperative condition that is not an expected outcome of hysterectomy and defined as instances in which a patient suffered hemorrhage, ureteral injury, bladder injury, intestinal injury, wound dehiscence, wound infection, deep vein thrombosis, pulmonary embolism, or required blood transfusion.
A total of 37 deaths were observed. Mortality was not significantly related to hospital volume or academic medical center status. In contrast, morbidity was found to have a positive association with academic medical center status (odds ratio = 1.34; 95% CI, 1.23 to 1.45), although an inverse relationship between volume and morbidity was observed for extended length of stay (> 3 days) and blood transfusion outcomes in the first 3 (lowest) volume quintiles and for pulmonary embolism in the highest-volume quintile. No important association with volume was found for hemorrhage, ureteral injury, bladder injury, or intestinal injury.
Unlike high-risk procedures, such as esophagectomy, pediatric cardiac surgery, and pancreaticoduodenectomy, mortality for abdominal hysterectomy done for benign indication does not improve with hospital volume or academic center status. The statistically significant positive association between academic medical center status and morbidity merits additional characterization to target areas for improvement.
高风险外科手术的手术量与手术结果之间的关系已得到确立。为了确定医院手术量和学术中心地位是否会影响低风险手术的手术结果，我们评估了因子宫肌瘤接受腹部子宫切除术患者的发病率和死亡率。
利用国家住院样本的管理数据，对1999年至2003年间172344例原发性诊断为平滑肌瘤（国际疾病分类第九版诊断代码前两位为218.x）且接受腹部子宫切除术（国际疾病分类第九版手术代码前两位为68.4）的患者进行回顾性分析。对教学医院与非教学医院以及按五分位数划分的年度病例数进行了比较。发病率被定义为子宫切除术后任何非预期的术后状况，包括患者发生出血、输尿管损伤、膀胱损伤、肠道损伤、伤口裂开、伤口感染、深静脉血栓形成、肺栓塞或需要输血的情况。
共观察到37例死亡。死亡率与医院手术量或学术医疗中心地位无显著相关性。相比之下，发病率与学术医疗中心地位呈正相关（优势比=1.34；95%可信区间，1.23至1.45），尽管在手术量最低的前三分位数中，住院时间延长（>3天）和输血结果以及手术量最高的五分位数中的肺栓塞方面，手术量与发病率呈负相关。在出血、输尿管损伤、膀胱损伤或肠道损伤方面未发现与手术量有重要关联。
与食管切除术、小儿心脏手术和胰十二指肠切除术等高风险手术不同，因良性指征进行的腹部子宫切除术的死亡率不会因医院手术量或学术中心地位的提高而改善。学术医疗中心地位与发病率之间具有统计学意义的正相关值得进一步分析，以确定改进目标领域。
Zotero 插件