Service Systems Research Unit, National Institute for Health and Welfare, PO Box 30, FI-00271 Helsinki, Finland.
BMC Health Serv Res. 2010 Aug 13;10:238. doi: 10.1186/1472-6963-10-238.
A common argument in the recent health policy debate is that treatment is more effective among care providers with large volumes. It is challenging, however, to examine the volume-effectiveness relationship empirically. Several suggestions have recently been made for methodological improvements in the examination of the volume-effectiveness relationship. The aim of this study is to develop an extended methodology for examining the volume-effectiveness relationship and demonstrate it for the case of hip fracture treatment.
Data consisting of 22,857 hip fracture patients from 52 hospitals in Finland in 1998-2001 were extracted from the administrative registers. The relationship between hospital and rehabilitation unit volumes and effectiveness was examined using a statistical model that allowed risk adjustments and hierarchical modeling of volume trends, developed for the purposes of this study. Four-month mortality and the alternative register-based measure of maintainability were used as effectiveness indicators.
No clear relationship was found between hospital volume and the effectiveness of hip fracture treatment, but a novel result showing an association between the rehabilitation unit volume and effectiveness was detected. The face validity of the maintainability indicator seemed to be acceptable.
The methodological ideas presented allow for improved examination of the volume-effectiveness relationship. There are no indications that patients with hip fractures should only be treated in high-volume hospitals, though it may be beneficial to centralize the rehabilitation of hip fracture patients to specialized units.
近期的健康政策辩论中，一个常见的观点是，在治疗中，高治疗量的医护人员的治疗效果更好。然而，从经验上检验治疗量与效果之间的关系具有挑战性。最近，人们对检验这种关系的方法提出了一些改进建议。本研究旨在提出一种扩展的方法来检验这种关系，并以髋部骨折治疗为例进行演示。
从芬兰 1998-2001 年 52 家医院的行政登记中提取了 22857 例髋部骨折患者的数据。使用一个允许风险调整和对趋势进行层次建模的统计模型，检验医院和康复单元的治疗量与效果之间的关系。该模型是为本次研究开发的。使用 4 个月死亡率和基于替代登记的维持率作为效果指标。
未发现医院治疗量与髋部骨折治疗效果之间存在明显的关系，但发现了一个新的结果，即康复单元的治疗量与效果之间存在关联。维持率指标的表面有效性似乎是可以接受的。
提出的方法思路允许更深入地检验治疗量与效果之间的关系。没有迹象表明髋部骨折患者只能在高治疗量的医院治疗，但将髋部骨折患者的康复集中到专门的单位可能会更有益。
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