Gasper Warren J, Glidden David V, Jin Chengshi, Way Lawrence W, Patti Marco G
Departments of Surgery, University of California, San Francisco, CA, USA.
Ann Surg. 2009 Sep;250(3):472-83. doi: 10.1097/SLA.0b013e3181b47c79.
Previous reports showed that in California during the early 1990s, operative mortality rates for esophageal, pancreatic, and hepatic cancers were inversely related to hospital volume. It is unknown whether this information has affected referral patterns or operative mortality rates.
Data were analyzed for the 10 years that followed the period covered in the initial studies to determine if: (a) the operative mortality rates had decreased; and (b) a greater proportion of patients with esophageal, pancreatic, and hepatic cancers were treated at high-volume centers.
Hospital discharge data were obtained for 8901 patients who had resections for cancer of the esophagus, 2404 patients; pancreas, 5294 patients; and liver, 1203 patients in California between 1995 and 2004. Logistic regression models were used to calculate adjusted mortality rates at high- and low-volume centers by year. The data were compared with the published results for California during the years 1990-1994.
Operative mortality rates decreased for esophageal, pancreatic, and hepatic resections during the more recent 10 years. Concomitantly, the proportion of patients treated at high-volume centers increased, as did the number of high-volume centers. There was a substantial increase in the proportion of esophagectomies performed in high-volume hospitals, while the overall number of esophagectomies dropped by 22%. For the other 2 operations, total volume and the volume in high-volume hospitals increased greatly, and the volume in low-volume hospitals was about the same during the 3 periods. The mortality rates decreased at all levels of the volume range. Finally, the performance from one period to the next in individual hospitals was mostly similar, but an occasional outlier was also noted.
More resections for esophageal, pancreatic, and hepatic cancer were performed at high volume centers, but mortality rates decreased for all hospital categories. The data suggest that modern hospitals act as complex adaptive systems, whose outputs are determined from the interactions between internal agents and are resistant to analysis by isolating and studying the individual contributions. It is tempting to attribute the desirable changes in these data (eg, more operations being done in high volume centers and better mortality rates at all levels) as consequences of pressures over the past few decades on hospitals to assume greater responsibility for their quality of care and to become more integrated internally.Thus, many factors appear to influence the volume-outcome relationships, and the identity and individual contributions of these influences may be immune to reductionist analysis. There is substantial evidence that high volume should be part of high quality for these complex operations. Nevertheless, measuring outcomes directly, rather than concentrating on their correlates, may be a more reliable index of hospital performance.
先前的报告显示，在20世纪90年代初的加利福尼亚州，食管癌、胰腺癌和肝癌的手术死亡率与医院规模呈负相关。尚不清楚这一信息是否影响了转诊模式或手术死亡率。
对初始研究涵盖时间段之后的10年数据进行分析，以确定：(a)手术死亡率是否下降；(b)食管癌、胰腺癌和肝癌患者在高容量中心接受治疗的比例是否更高。
获取了1995年至2004年期间加利福尼亚州8901例接受食管癌切除术的患者、2404例接受胰腺癌切除术的患者、5294例接受肝癌切除术的患者以及1203例其他患者的医院出院数据。使用逻辑回归模型按年份计算高容量和低容量中心的调整后死亡率。将这些数据与1990 - 1994年加利福尼亚州已发表的结果进行比较。
在最近10年中，食管癌、胰腺癌和肝癌切除术的手术死亡率有所下降。与此同时，在高容量中心接受治疗的患者比例增加，高容量中心的数量也增加。高容量医院进行的食管切除术比例大幅增加，而食管切除术的总数下降了22%。对于其他两种手术，总体手术量和高容量医院的手术量大幅增加，低容量医院的手术量在三个时期大致相同。各容量范围的死亡率均有所下降。最后，各个医院在不同时期的表现大多相似，但也偶尔会出现异常值。
高容量中心进行的食管癌、胰腺癌和肝癌切除术增多，但所有医院类别的死亡率均下降。数据表明，现代医院就像复杂适应系统，其产出由内部因素之间的相互作用决定，难以通过孤立和研究个体贡献进行分析。人们很容易将这些数据中理想的变化（例如，高容量中心进行的手术增多以及各层面更好的死亡率）归因于过去几十年医院面临的压力，即要求它们对医疗质量承担更大责任并在内部实现更高程度的整合。因此，许多因素似乎影响着手术量 - 结果关系，这些影响的性质和个体贡献可能无法通过简化分析来确定。有大量证据表明，对于这些复杂手术，高手术量应是高质量的一部分。然而，直接衡量结果而非专注于其相关因素，可能是衡量医院表现更可靠的指标。
