Division of Cardiothoracic Surgery, University of Washington Medical School, Seattle, Washington 98195, USA.
Ann Thorac Surg. 2011 Apr;91(4):1003-9; discussion 1009-10. doi: 10.1016/j.athoracsur.2010.11.006.
The Leapfrog Group established a minimum hospital case volume of 13 for esophageal resection in a response to known improved outcomes in larger volume centers. The aim of this study was to evaluate variation in short-term outcomes among hospitals that met the Leapfrog volume criteria.
Using the Washington State Comprehensive Hospital Abstract Reporting System, a retrospective cohort design evaluated all patients (≥18 years) undergoing esophageal resection for any diagnosis since the introduction of Leapfrog standards (2000 to 2007). The main outcome measures were hospital stay, readmissions within 30 days of discharge, discharge to an institutional care facility, operative reinterventions, and 90-day mortality.
A total of 1,505 adult Washington state residents underwent esophageal resection without complex reconstruction (1,352 elective [89.8%]). Of 45 hospitals reporting at least one procedure, 5 (11%) met Leapfrog volume standards. Leapfrog hospitals accounted for 62% of the total elective volume. Overall, elective patients at Leapfrog hospitals had a lower adjusted risk of death compared with those at hospitals that did not meet criteria (odds ratio 0.50, p = 0.02). Across the different Leapfrog hospitals there was over fivefold variation in 90-day mortality (1.7% to 10.2%), 2.5-fold variation in reinterventions (8% to 20%), and fourfold variation in discharges to an institutional care facility (5.3% to 19.8%). Length of stay and readmission rate varied less.
Although referral to high-volume centers has been an important advance for complex surgical procedures, there is still a substantial degree of variability in outcomes among hospitals that met Leapfrog volume criteria for esophagectomy. Metrics such as process, individual surgeon volume, and risk-adjusted outcome measures may yield further opportunities for quality improvement that extend beyond hospital volume-based assessments.
Leapfrog 集团针对在大容量中心获得更好结果的情况，设定了食管切除术的最低医院病例量为 13 例。本研究旨在评估符合 Leapfrog 容量标准的医院之间短期结果的差异。
使用华盛顿州综合医院摘要报告系统，回顾性队列设计评估了自 Leapfrog 标准引入以来（2000 年至 2007 年）所有接受食管切除术的患者（≥18 岁）。主要结局指标为住院时间、出院后 30 天内再入院、出院至机构护理设施、手术再干预和 90 天死亡率。
共有 1505 名华盛顿州成年居民接受了不包括复杂重建的食管切除术（1352 例为择期手术[89.8%]）。在报告至少进行了一次手术的 45 家医院中，有 5 家（11%）符合 Leapfrog 容量标准。Leapfrog 医院占总择期手术量的 62%。总体而言，与不符合标准的医院相比，Leapfrog 医院的择期手术患者死亡风险较低（优势比 0.50，p=0.02）。在不同的 Leapfrog 医院之间，90 天死亡率差异超过五倍（1.7%至 10.2%），再干预率差异两倍（8%至 20%），出院至机构护理设施的比例差异四倍（5.3%至 19.8%）。住院时间和再入院率变化较小。
尽管向高容量中心转诊是复杂手术的重要进展，但在符合 Leapfrog 食管切除术容量标准的医院之间，结果仍存在很大差异。过程、个别外科医生的手术量和风险调整后的结果指标等指标可能会为质量改进提供进一步机会，超出基于医院容量的评估范围。
