Ghaferi Amir A, Birkmeyer John D, Dimick Justin B
Michigan Surgical Collaborative for Outcomes Research and Evaluation, the Department of Surgery, University of Michigan, Ann Arbor 48104, USA.
N Engl J Med. 2009 Oct 1;361(14):1368-75. doi: 10.1056/NEJMsa0903048.
Hospital mortality that is associated with inpatient surgery varies widely. Reducing rates of postoperative complications, the current focus of payers and regulators, may be one approach to reducing mortality. However, effective management of complications once they have occurred may be equally important.
We studied 84,730 patients who had undergone inpatient general and vascular surgery from 2005 through 2007, using data from the American College of Surgeons National Surgical Quality Improvement Program. We first ranked hospitals according to their risk-adjusted overall rate of death and divided them into five groups. For hospitals in each overall mortality quintile, we then assessed the incidence of overall and major complications and the rate of death among patients with major complications.
Rates of death varied widely across hospital quintiles, from 3.5% in very-low-mortality hospitals to 6.9% in very-high-mortality hospitals. Hospitals with either very high mortality or very low mortality had similar rates of overall complications (24.6% and 26.9%, respectively) and of major complications (18.2% and 16.2%, respectively). Rates of individual complications did not vary significantly across hospital mortality quintiles. In contrast, mortality in patients with major complications was almost twice as high in hospitals with very high overall mortality as in those with very low overall mortality (21.4% vs. 12.5%, P<0.001). Differences in rates of death among patients with major complications were also the primary determinant of variation in overall mortality with individual operations.
In addition to efforts aimed at avoiding complications in the first place, reducing mortality associated with inpatient surgery will require greater attention to the timely recognition and management of complications once they occur.
与住院手术相关的医院死亡率差异很大。降低术后并发症发生率是目前支付方和监管机构关注的重点，这可能是降低死亡率的一种方法。然而，并发症一旦发生，对其进行有效管理可能同样重要。
我们利用美国外科医师学会国家外科质量改进项目的数据，研究了2005年至2007年期间接受住院普通外科和血管外科手术的84730例患者。我们首先根据风险调整后的总体死亡率对医院进行排名，并将它们分为五组。然后，对于每个总体死亡率五分位数组中的医院，我们评估总体和主要并发症的发生率以及主要并发症患者的死亡率。
各医院五分位数组的死亡率差异很大，极低死亡率医院为3.5%，极高死亡率医院为6.9%。总体死亡率极高或极低的医院总体并发症发生率（分别为24.6%和26.9%）和主要并发症发生率（分别为18.2%和16.2%）相似。各医院死亡率五分位数组的个体并发症发生率没有显著差异。相比之下，总体死亡率极高的医院中主要并发症患者的死亡率几乎是总体死亡率极低的医院的两倍（21.4%对12.5%，P<0.001）。主要并发症患者死亡率的差异也是个体手术总体死亡率差异的主要决定因素。
除了首先致力于避免并发症外，降低与住院手术相关的死亡率还需要更加关注并发症一旦发生时的及时识别和管理。
