Mount Sinai School of Medicine, New York, NY 10029, USA.
N Engl J Med. 2010 Mar 25;362(12):1110-8. doi: 10.1056/NEJMsa0907130.
The association between hospital volume and the death rate for patients who are hospitalized for acute myocardial infarction, heart failure, or pneumonia remains unclear. It is also not known whether a volume threshold for such an association exists.
We conducted cross-sectional analyses of data from Medicare administrative claims for all fee-for-service beneficiaries who were hospitalized between 2004 and 2006 in acute care hospitals in the United States for acute myocardial infarction, heart failure, or pneumonia. Using hierarchical logistic-regression models for each condition, we estimated the change in the odds of death within 30 days associated with an increase of 100 patients in the annual hospital volume. Analyses were adjusted for patients' risk factors and hospital characteristics. Bootstrapping procedures were used to estimate 95% confidence intervals to identify the condition-specific volume thresholds above which an increased volume was not associated with reduced mortality.
There were 734,972 hospitalizations for acute myocardial infarction in 4128 hospitals, 1,324,287 for heart failure in 4679 hospitals, and 1,418,252 for pneumonia in 4673 hospitals. An increased hospital volume was associated with reduced 30-day mortality for all conditions (P<0.001 for all comparisons). For each condition, the association between volume and outcome was attenuated as the hospital's volume increased. For acute myocardial infarction, once the annual volume reached 610 patients (95% confidence interval [CI], 539 to 679), an increase in the hospital volume by 100 patients was no longer significantly associated with reduced odds of death. The volume threshold was 500 patients (95% CI, 433 to 566) for heart failure and 210 patients (95% CI, 142 to 284) for pneumonia.
Admission to higher-volume hospitals was associated with a reduction in mortality for acute myocardial infarction, heart failure, and pneumonia, although there was a volume threshold above which an increased condition-specific hospital volume was no longer significantly associated with reduced mortality.
医院的容量与因急性心肌梗死、心力衰竭或肺炎住院的患者的死亡率之间的关联尚不清楚。也不知道是否存在这样的关联的容量阈值。
我们对美国急性护理医院在 2004 年至 2006 年间因急性心肌梗死、心力衰竭或肺炎住院的所有按服务收费的医疗保险受益人的行政索赔数据进行了横断面分析。对于每种情况，我们使用分层逻辑回归模型，估计与医院年度容量增加 100 名患者相关的 30 天内死亡的几率变化。分析结果根据患者的风险因素和医院特征进行了调整。采用自举程序来估计 95%置信区间，以确定特定于病情的容量阈值，超过该阈值，增加的容量与降低死亡率无关。
在 4128 家医院中有 734972 例急性心肌梗死住院治疗，在 4679 家医院中有 1324287 例心力衰竭住院治疗，在 4673 家医院中有 1418252 例肺炎住院治疗。对于所有情况，医院容量的增加与 30 天死亡率的降低相关（所有比较 P<0.001）。对于每种情况，随着医院容量的增加，容量与结果之间的关联减弱。对于急性心肌梗死，一旦年度容量达到 610 例（95%置信区间[CI]，539 至 679），医院容量增加 100 例与降低死亡几率不再显著相关。容量阈值为 500 例（95%CI，433 至 566）用于心力衰竭，210 例（95%CI，142 至 284）用于肺炎。
入住高容量医院与急性心肌梗死、心力衰竭和肺炎的死亡率降低相关，尽管存在一个容量阈值，超过该阈值，增加的特定于病情的医院容量与死亡率降低不再显著相关。
