Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago2Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor.
Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor.
JAMA Surg. 2014 Feb;149(2):119-23. doi: 10.1001/jamasurg.2013.3649.
To effectively guide interventions aimed at reducing mortality in low-volume hospitals, the underlying mechanisms of the volume-outcome relationship must be further explored. Reducing mortality after major postoperative complications may represent one point along the continuum of patient care that could significantly affect overall hospital mortality.
To determine whether increased mortality at low-volume hospitals performing cardiovascular surgery is a function of higher postoperative complication rates or of less successful rescue from complications.
DESIGN, SETTING, AND PARTICIPANTS: We used patient-level data from 119434 Medicare fee-for-service beneficiaries aged 65 to 99 years undergoing coronary artery bypass grafting, aortic valve repair, or abdominal aortic aneurysm repair between January 1, 2005, and December 31, 2006. For each operation, we first divided hospitals into quintiles of procedural volume. We then assessed hospital risk-adjusted rates of mortality, major complications, and failure to rescue (ie, case fatality among patients with complications) within each volume quintile.
Hospital procedural volume.
Hospital rates of risk-adjusted mortality, major complications, and failure to rescue.
For each operation, hospital volume was more strongly related to failure-to-rescue rates than to complication rates. For example, patients undergoing aortic valve replacement at very low-volume hospitals (lowest quintile) were 12% more likely to have a major complication than those at very high-volume hospitals (highest quintile) but were 57% more likely to die if a complication occurred.
High-volume and low-volume hospitals performing cardiovascular surgery have similar complication rates but disparate failure-to-rescue rates. While preventing complications is important, hospitals should also consider interventions aimed at quickly recognizing and managing complications once they occur.
为了有效指导旨在降低低容量医院死亡率的干预措施，必须进一步探讨量效关系的潜在机制。降低重大术后并发症后的死亡率可能代表着患者护理连续体上的一个点，这可能会显著影响整体医院死亡率。
确定在进行心血管手术的低容量医院中，死亡率增加是否是术后并发症发生率较高的结果，还是并发症救治成功率较低的结果。
设计、环境和参与者：我们使用了来自 119434 名年龄在 65 至 99 岁之间的 Medicare 按服务收费受益人的患者水平数据，这些患者在 2005 年 1 月 1 日至 2006 年 12 月 31 日期间接受了冠状动脉旁路移植术、主动脉瓣修复术或腹主动脉瘤修复术。对于每种手术，我们首先将医院分为手术量五分位数。然后，我们在每个体积五分位数内评估了医院风险调整后的死亡率、主要并发症和救援失败率（即有并发症患者的病例死亡率）。
医院手术量。
医院风险调整死亡率、主要并发症和救援失败率。
对于每种手术，医院的量效关系与救援失败率的关系比与并发症发生率的关系更为密切。例如，在低容量医院（最低五分位数）接受主动脉瓣置换术的患者发生重大并发症的可能性比在高容量医院（最高五分位数）的患者高 12%，但如果发生并发症，他们死亡的可能性高 57%。
进行心血管手术的高容量和低容量医院的并发症发生率相似，但救援失败率不同。虽然预防并发症很重要，但医院还应考虑采取干预措施，一旦发生并发症，就迅速识别和处理并发症。
