Division of Thoracic Surgery, St. Joseph's Hospital, Hamilton, Ontario, Canada.
Ann Thorac Surg. 2011 Aug;92(2):485-90; discussion 490. doi: 10.1016/j.athoracsur.2011.02.089. Epub 2011 Jun 25.
Regionalization of specialized surgical services has been proposed to improve outcomes based on the reported association between volume and outcomes. The effect of regionalization of esophagectomy on in-hospital mortality (IHM) and length of stay (LOS) was examined.
Data from a Canadian database for 6985 patients (74% men; median age, 66 years) who underwent esophagectomy (1998 to 2007) were analyzed with a multivariable mixed model regression controlling for age, sex, Charlson comorbidity index, and year of esophagectomy to evaluate the effect of hospital volume. Volume changes were evaluated within and between hospitals.
From 1998 to 2007, the number of hospitals performing esophagectomies decreased (101 to 85). The percentage of patients treated in large-volume (>20 cases/year) centers increased (29% to 61%) and IHM decreased (9.1% to 3.6%). The odds of IHM decreased 64% (95% confidence interval [CI], 51% to 74%), and LOS decreased 38% (95% CI, 34% to 43%). Comparing between hospitals, an increase of 10 cases was associated with a 15% decrease in IHM (95% CI, 6% to 23%, p=0.001) and a 10% increase in LOS (95% CI, 2% to 19%, p=0.01). Within an individual hospital, the relationship between increasing volume and LOS or IHM was not significant.
In-hospital mortality for esophagectomy has decreased in Canada but was not significantly reduced when volume was increased within a given hospital. Improved IHM may be related to selective referral of patients to high-volume hospitals. Although, decreased IHM is not solely attributable to volume changes, our results support regionalization policies for esophagectomy.
根据报道的手术量与结果之间的关联，提出了将专业外科手术服务区域化，以改善结果。本文研究了食管癌切除术的区域化对住院死亡率（IHM）和住院时间（LOS）的影响。
对加拿大数据库中 6985 例（74%为男性；中位年龄为 66 岁）食管癌患者（1998 年至 2007 年）的数据进行了多变量混合模型回归分析，控制了年龄、性别、Charlson 合并症指数和食管癌手术年份，以评估医院容量的影响。评估了医院内和医院间的容量变化。
1998 年至 2007 年，行食管癌切除术的医院数量减少（101 家至 85 家）。在大手术量（>20 例/年）中心治疗的患者比例增加（29%至 61%），IHM 降低（9.1%至 3.6%）。IHM 的发生风险降低了 64%（95%可信区间，51%至 74%），LOS 降低了 38%（95%可信区间，34%至 43%）。比较医院间，手术量增加 10 例与 IHM 降低 15%相关（95%可信区间，6%至 23%，p=0.001），LOS 增加 10%相关（95%可信区间，2%至 19%，p=0.01）。在单个医院内，增加手术量与 LOS 或 IHM 之间没有显著关系。
在加拿大，食管癌手术的住院死亡率有所下降，但在特定医院增加手术量时，死亡率并没有显著降低。IHM 的改善可能与患者被选择性转诊到高手术量医院有关。尽管 IHM 的降低不仅仅归因于手术量的变化，但我们的结果支持食管癌的区域化政策。
