[结直肠手术的质量评估取决于医院的医疗保健类别——结果差异不大，但过程质量仍有改进空间]
[Quality evaluation in colorectal surgery in dependence on health-care categories of hospitals - minor differences in outcome with room for improvement in process quality].
作者信息
Scheidbach H, Kube R, Schmidt U, Robra B-P, Gastinger I, Lippert H
机构信息
Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Otto-von-Guericke-Universität Magdeburg, Magdeburg.
出版信息
Gesundheitswesen. 2011 Mar;73(3):134-9. doi: 10.1055/s-0029-1246214. Epub 2010 Mar 3.
BACKGROUND
In the present study, different variables focusing on quality of colorectal surgery were investigated with respect to hospital categories: university hospital - U; hospital with maximum care responsibility (with a full spectrum of medical disciplines) - M; secondary care hospital with central regional responsibility (6-9 departments) - S; primary care hospital with local responsibility (2-5 departments) - G; The primary goal of this study was to analyse the current standard of care in patients with colorectal carcinoma in Germany.
METHODS
From 2000-2004, data of 47 435 patients with colorectal cancer were evaluated, using data compiled in the German multi-centred observational study "Colon/Rectal Carcinoma". Analysis was performed for all variables with respect to hospital categories. Due to the remarkable number of patients, differences between the groups were to be regarded as significant if p<0.01.
RESULTS
Preoperative colonoscopy (U: 70.1% M: 70.4% S: 67.9% G: 67.2) and preoperative determination of serum tumour markers (U: 83.8% M: 80.1% S: 81.9% G: 77.1) mainly indicate the quality of gastroenterological work-up before surgical intervention. In general, standards established by the "German Cancer Association" were not met and showed significantly lower rates for primary and secondary care hospitals. In contrast, variables indicating quality of perioperative course and outcome: rate of anastomotic leak (U: 2.1% M: 2.8% S: 2.1% G: 3.1%), rate of surgical intervention (U: 4.3% M: 3.1% S: 3.5% G: 3.1%) and mortality rate (U: 4.4% M: 2.2% S: 3.5% G: 4.1%) were in accordance with the requirements and did not differ significantly between all groups. However, an analysis of surgical and histopathological process quality (complete histology: U: 96.3% M: 93.6% S: 91.9% G: 90.9%) revealed significant differences with results being significantly lower for primary care hospitals.
CONCLUSION
There is in principle no necessity to centre colorectal surgery in tertiary care hospitals as quality parameters focusing on results and outcome are comparable. However, in primary care hospitals, there are deficits with regards to process quality. Therefore, all measures aiming to enhance in particular process quality, i. e., hospital certification or participation with quality assurance studies, are highly desirable to further improve patient care.
背景
在本研究中，针对不同类别医院，对结直肠手术质量的不同变量进行了调查：大学医院——U；承担最高护理责任的医院（具备全医学学科）——M；承担区域中心责任的二级护理医院（6 - 9个科室）——S；承担地方责任的初级护理医院（2 - 5个科室）——G；本研究的主要目的是分析德国结直肠癌患者当前的护理标准。
方法
2000 - 2004年期间，利用德国多中心观察性研究“结肠/直肠癌”中汇编的数据，对47435例结直肠癌患者的数据进行了评估。针对所有变量按医院类别进行了分析。由于患者数量众多，如果p<0.01，则各组之间的差异被视为具有显著性。
结果
术前结肠镜检查（U：70.1%，M：70.4%，S：67.9%，G：67.2%）和术前血清肿瘤标志物测定（U：83.8%，M：80.1%，S：81.9%，G：77.1%）主要表明手术干预前胃肠病学检查的质量。总体而言，未达到“德国癌症协会”制定的标准，一级和二级护理医院的达标率显著较低。相比之下，表明围手术期过程和结果质量的变量：吻合口漏发生率（U：2.1%，M：2.8%，S：2.1%，G：3.1%）、手术干预率（U：4.3%，M：3.1%，S：3.5%，G：3.1%）和死亡率（U：4.4%，M：2.2%，S：3.5%，G：4.1%）符合要求，且各组之间无显著差异。然而，对手术和组织病理学过程质量的分析（完整组织学：U：96.3%，M：93.6%，S：91.9%，G：90.9%）显示存在显著差异，一级护理医院的结果显著更低。
结论
原则上没有必要将结直肠手术集中在三级护理医院，因为关注结果和预后的质量参数具有可比性。然而，一级护理医院在过程质量方面存在不足。因此，所有旨在特别提高过程质量的措施，即医院认证或参与质量保证研究，对于进一步改善患者护理非常必要。
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