Gorin Michael A, Kates Max, Mullins Jeffrey K, Pierorazio Phillip M, Matlaga Brian R, Schoenberg Mark P, Bivalacqua Trinity J
The Johns Hopkins School of Medicine, Baltimore, MD, USA.
Can J Urol. 2014 Feb;21(1):7102-7.
The objective of this study was to evaluate the impact of hospital case volume on perioperative outcomes and costs of radical cystectomy (RC) after controlling for differences in patient case mix.
The Maryland Health Services Cost Review Commission database was queried for patients who underwent an open RC between 2000 and 2011. Patients were divided into tertiles based on hospital case volume. Groups were compared for differences in length of intensive care unit (ICU) stay, length of total hospital stay, rate of in-hospital deaths and procedure-related costs.
In total, 1620 patients underwent a RC during the study period. Of these patients, 457 (28.2%) underwent surgery at 37 low volume centers, 465 (28.7%) at six mid volume centers and 698 (43.1%) at a single high volume center. The mean case volume of each group was 1.1, 7.0 and 63.5 RC/center/year, respectively. After controlling for marked differences in patient case mix, having surgery at the single high-volume center was independently associated with a decrease in length of ICU stay (coefficient = -0.41 days, 95% CI -0.78--0.05, p = 0.03), in-hospital mortality (OR 0.18, 95% CI 0.04-0.80, p = 0.02) and total medical costs (coefficient = -2.91k USD, 95% CI -4.15--1.67, p < 0.001). Decreased total costs were driven by reductions in charges associated with the operating room, drugs, radiology tests, labs, supplies and physical/occupational therapy (all p < 0.001).
Undergoing RC at a high volume medical center was associated with improved outcomes and reduced costs. These data support the centralization of RC to high volume centers.
本研究的目的是在控制患者病例组合差异后，评估医院病例数量对根治性膀胱切除术（RC）围手术期结局和费用的影响。
查询马里兰州医疗服务成本审查委员会数据库，获取2000年至2011年间接受开放性RC手术的患者信息。根据医院病例数量将患者分为三分位数。比较各组在重症监护病房（ICU）住院时间、总住院时间、院内死亡率和手术相关费用方面的差异。
在研究期间，共有1620例患者接受了RC手术。其中，457例（28.2%）在37个低容量中心接受手术，465例（28.7%）在6个中等容量中心接受手术，698例（43.1%）在单个高容量中心接受手术。每组的平均病例数量分别为每个中心每年1.1例、7.0例和63.5例RC手术。在控制患者病例组合的显著差异后，在单个高容量中心进行手术与ICU住院时间缩短（系数=-0.41天，95%置信区间-0.78--0.05，p=0.03）、院内死亡率降低（比值比0.18，95%置信区间0.04-0.80，p=0.02）和总医疗费用降低（系数=-2910美元，95%置信区间-4150--1670，p<0.001）独立相关。总成本的降低是由手术室、药物、放射学检查、实验室检查、用品以及物理/职业治疗相关费用的减少所驱动的（所有p<0.001）。
在高容量医疗中心进行RC手术与改善结局和降低费用相关。这些数据支持将RC手术集中到高容量中心。
