Division of Pediatric Surgery, Department of Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St Louis, MO 63110, USA.
Ann Surg. 2010 Oct;252(4):635-42. doi: 10.1097/SLA.0b013e3181f5b538.
Congenital diaphragmatic hernia (CDH) remains a significant cause of neonatal morbidity and mortality.
Previous studies have suggested that hospital volume is an independent predictor of in-hospital mortality. We sought to validate this effect using a large national database incorporating 37 free-standing children's hospitals in the United States.
Infants who underwent repair of CDH from 2000 to 2008 at Pediatric Health Information Systems-member hospitals were evaluated. Hospitals were categorized by tertiles into low-volume (≤6 cases/yr), medium-volume (6-10 cases/yr), and high-volume (>10 cases/yr). Using generalized linear mixed models with random effects, we computed the risk-adjusted odds ratio of mortality by yearly hospital volume of CDH repair, after adjustment for salient patient and hospital characteristics.
There were 2203 infants who underwent repair with an overall survival of 82%. Average yearly hospital volume of CDH repair varied from 1.4 to 17.5 cases per year. Smaller birthweight (adjusted odds ratio [aOR]: 0.56 per kg, P < 0.001), year of birth (P < 0.001), chromosomal abnormalities (aOR: 3.83, P < 0.01), longer time to repair (aOR: 1.12 per week, P < 0.05), the thoracic approach for repair (P < 0.02), and requirement for extracorporeal membrane oxygenation (aOR: 10.31, P < 0.0001), or inhaled nitric oxide (aOR: 5.25, P < 0.0001) were each independently associated with mortality. Compared with low-volume hospitals, medium-volume (aOR: 0.56, P < 0.05) and high-volume (aOR: 0.44, P < 0.01) hospitals had a significantly lower mortality. The rate of extracorporeal membrane oxygenation use at each facility was not independently associated with mortality.
This large study suggests that hospitals which perform high volumes of CDH repair achieve lower in-hospital mortality. These data support the paradigm of regionalized centers of excellence for the management of infants with this morbid condition.
先天性膈疝（CDH）仍然是新生儿发病率和死亡率的重要原因。
先前的研究表明，医院容量是住院死亡率的独立预测因素。我们试图使用包含美国 37 家独立儿童医院的大型国家数据库来验证这种效果。
对 2000 年至 2008 年在儿科健康信息系统成员医院接受 CDH 修复的婴儿进行评估。根据 tertiles，将医院分为低容量（≤6 例/年）、中容量（6-10 例/年）和高容量（>10 例/年）。使用具有随机效应的广义线性混合模型，在校正了显著的患者和医院特征后，我们计算了每年 CDH 修复医院容量的死亡率调整后比值比。
共有 2203 名婴儿接受了修复手术，总体存活率为 82%。每年 CDH 修复的平均医院容量从每年 1.4 例到 17.5 例不等。较小的出生体重（调整后的比值比[aOR]：每公斤 0.56，P < 0.001）、出生年份（P < 0.001）、染色体异常（aOR：3.83，P < 0.01）、修复时间较长（aOR：每周 1.12 周，P < 0.05）、采用胸腔入路进行修复（P < 0.02）、需要体外膜氧合（aOR：10.31，P < 0.0001）或吸入一氧化氮（aOR：5.25，P < 0.0001），这些因素都与死亡率独立相关。与低容量医院相比，中容量（aOR：0.56，P < 0.05）和高容量（aOR：0.44，P < 0.01）医院的死亡率显著降低。每个机构使用体外膜氧合的比率与死亡率无关。
这项大型研究表明，进行大量 CDH 修复的医院的院内死亡率较低。这些数据支持为管理这种严重疾病建立卓越区域中心的模式。
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