教学状态：对美国急诊和择期手术护理的影响。

Teaching status: the impact on emergency and elective surgical care in the US.

机构信息

Department of Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA.

出版信息

Ann Surg. 2011 May;253(5):1017-23. doi: 10.1097/SLA.0b013e3182171fd1.

Abstract

OBJECTIVE(S): To examine the relation between hospital teaching status and surgical outcomes for both emergency and elective general surgery cases using a national database.

BACKGROUND

Teaching hospitals (TH) have been shown to have better outcomes for complex elective surgical cases when compared with nonteaching hospitals (NTH). Less is known about the effect of teaching status on outcomes for more common procedures, especially where emergency surgical cases are concerned. Worse outcomes seen in this cohort are often attributed to patient disease, but systems level variables such as TH status may also play a role.

METHODS

We performed a nationally representative retrospective cohort study of surgical admissions during 2000 to 2006 using the Nationwide Inpatient Sample. Patients were included if they were more than 18 years of age and had a general surgical procedure performed on the day of admission. We examined unadjusted and adjusted in-hospital mortality (IHM) and postoperative complications (POC) for elective and emergency patients.

RESULTS

We identified 1,052,809 admissions. Patients treated at THs were more likely to be nonwhite and at extremes of income when compared with those treated at NTH. Adjusted outcomes revealed an increased risk of IHM at TH (overall OR = 1.20; 95% CI 1.03-1.40, P = 0.017) for emergency admissions with no difference in IHM seen after elective procedures. Postoperative infections were more likely to occur at TH than NTH after elective procedures (OR = 1.14; 95% CI 1.06-1.17, P < 0.007). Postoperative fistula was more likely to occur at TH than NTH after elective surgery (OR = 1.56; 95% CI 1.32-1.85, P < 0.005) whereas postoperative ileus was less likely to occur at TH than NTH (OR = 0.82; 95% CI 0.74-0.91, P = 0.002).

CONCLUSIONS

Teaching status is associated with increased risk of IHM after emergency cases. POC profiles also differ by TH status. Investigation of the way in which systems-level variables that differ between TH and NTH contribute to postoperative outcomes may identify novel targets for performance improvement.

摘要

目的

利用国家数据库研究医院教学状况与急诊和择期普外科手术结果之间的关系。

背景

与非教学医院（NTH）相比，教学医院（TH）的复杂择期手术结果更好。关于教学状况对更常见手术结果的影响，了解较少，尤其是在涉及急诊手术的情况下。在这一队列中看到的较差结果通常归因于患者疾病，但系统水平变量（如 TH 状态）也可能起作用。

方法

我们使用全国住院患者样本进行了 2000 年至 2006 年的全国代表性回顾性队列研究。如果患者年龄超过 18 岁且在入院当天进行了普外科手术，则将其纳入研究。我们检查了择期和急诊患者的未调整和调整后的住院死亡率（IHM）和术后并发症（POC）。

结果

我们确定了 1,052,809 例入院病例。与 NTH 治疗的患者相比，TH 治疗的患者更可能是非裔美国人，并且收入处于极端水平。调整后的结果显示，急诊入院时 TH 发生 IHM 的风险增加（总体 OR = 1.20；95% CI 1.03-1.40，P = 0.017），而择期手术则没有 IHM 差异。与 NTH 相比，TH 后择期手术后发生感染的可能性更大（OR = 1.14；95% CI 1.06-1.17，P < 0.007）。TH 比 NTH 更有可能在择期手术后发生术后瘘（OR = 1.56；95% CI 1.32-1.85，P < 0.005），而术后肠梗阻的可能性更小TH 比 NTH（OR = 0.82；95% CI 0.74-0.91，P = 0.002）。