Division of Pediatric Surgery, University of California Los Angeles School of Medicine, Los Angeles, CA 90095, USA.
Ann Surg. 2010 Jun;251(6):1162-6. doi: 10.1097/SLA.0b013e3181c98271.
To determine the impact of evidence-based guidelines on the disparities in management of pediatric splenic injuries (PSI).
Several studies have highlighted a disparity in the utilization of nonoperative management (NOM) for PSI based on hospital and surgeon characteristics. Whether evidence-based guidelines had an impact on mitigating this disparity is uncertain.
From 1999 to 2006, children < or = 18 years with PSI were extracted from California's Patient Discharge Database (n = 5089). Patient demographics, injury grade, immediate and delayed operations, readmissions, and complications were analyzed.
The overall rates of immediate operative management (IOM) decreased significantly from 23% in 1999 to 15% in 2006 (P < 0.001). This decline was attributed entirely to reduction of IOM at non-children's hospitals (NCH) (29% to 20%, P < 0.001). In contrast, IOM rates were low and unchanged at children's hospital (CH) (9%, P = NS). Failed NOM (3.3%), readmissions for complications (0.6%), and operations (0.3%) were rare and unaffected by NOM increase. NCH had increased risk of IOM compared to CH in multivariate analysis (OR: 2.00, 99% CI: 1.09-3.57). The rate of delayed splenic rupture was 0.2%. There were no differences when comparing the rates of readmissions (1.0% vs. 0.4%, P = NS) and readmit operations (0.3% vs. 0.3%, P = NS) between IOM versus NOM.
A steady increase in the utilization of NOM for PSI in California over time was attributed entirely to changing practices at NCH. Increasing NOM has occurred without a concurrent increase in complications. Delayed splenic ruptures were rare. Although IOM rates at NCH decreased over time, disparity in NOM utilization still exists between NCH and CH.
确定循证指南对小儿脾损伤（PSI）管理差异的影响。
多项研究强调，基于医院和外科医生的特征，PSI 中非手术治疗（NOM）的应用存在差异。但循证指南是否能减轻这种差异尚不确定。
从 1999 年至 2006 年，从加利福尼亚州患者出院数据库中提取了年龄≤18 岁的脾损伤患儿（n=5089）。分析了患者的人口统计学特征、损伤程度、立即手术和延迟手术、再入院和并发症。
立即手术治疗（IOM）的总体比例从 1999 年的 23%显著下降到 2006 年的 15%（P＜0.001）。这种下降完全归因于非儿童医院（NCH）IOM 比例的降低（从 29%降至 20%，P＜0.001）。相比之下，儿童医院（CH）的 IOM 比例较低且保持不变（9%，P=NS）。NOM 失败（3.3%）、并发症再入院（0.6%）和手术（0.3%）很少发生，不受 NOM 增加的影响。多因素分析显示，NCH 与 CH 相比，IOM 的风险增加（OR：2.00，99%CI：1.09-3.57）。延迟性脾破裂的发生率为 0.2%。IOM 与 NOM 相比，再入院率（1.0%比 0.4%，P=NS）和再入院手术率（0.3%比 0.3%，P=NS）没有差异。
随着时间的推移，加利福尼亚州 PSI 中 NOM 的应用稳步增加，这完全归因于 NCH 实践的改变。NOM 的增加并未导致并发症的增加。延迟性脾破裂很少见。尽管 NCH 的 IOM 率随时间降低，但 NCH 和 CH 之间的 NOM 使用差异仍然存在。
