Wong Sandra L, Revels ShaʼShonda L, Yin Huiying, Stewart Andrew K, McVeigh Andrea, Banerjee Mousumi, Birkmeyer John D
*Center for Healthcare Outcomes and Policy and Department of Surgery, University of Michigan Medical School, Ann Arbor †Remedy Informatics, Chicago, IL; and ‡Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor.
Ann Surg. 2015 Apr;261(4):632-6. doi: 10.1097/SLA.0000000000000690.
To elucidate clinical mechanisms underlying variation in hospital mortality after cancer surgery
: Thousands of Americans die every year undergoing elective cancer surgery. Wide variation in hospital mortality rates suggest opportunities for improvement, but these efforts are limited by uncertainty about why some hospitals have poorer outcomes than others.
Using data from the 2006-2007 National Cancer Data Base, we ranked 1279 hospitals according to a composite measure of perioperative mortality after operations for bladder, esophagus, colon, lung, pancreas, and stomach cancers. We then conducted detailed medical record review of 5632 patients at 1 of 19 hospitals with low mortality rates (2.1%) or 30 hospitals with high mortality rates (9.1%). Hierarchical logistic regression analyses were used to compare risk-adjusted complication incidence and case-fatality rates among patients experiencing serious complications.
The 7.0% absolute mortality difference between the 2 hospital groups could be attributed to higher mortality from surgical site, pulmonary, thromboembolic, and other complications. The overall incidence of complications was not different between hospital groups [21.2% vs 17.8%; adjusted odds ratio (OR) = 1.34, 95% confidence interval (CI): 0.93-1.94]. In contrast, case-fatality after complications was more than threefold higher at high mortality hospitals than at low mortality hospitals (25.9% vs 13.6%; adjusted OR = 3.23, 95% CI: 1.56-6.69).
Low mortality and high mortality hospitals are distinguished less by their complication rates than by how frequently patients die after a complication. Strategies for ensuring the timely recognition and effective management of postoperative complications will be essential in reducing mortality after cancer surgery.
阐明癌症手术后医院死亡率差异背后的临床机制
每年有成千上万的美国人在接受择期癌症手术时死亡。医院死亡率差异很大，这表明有改进的空间，但由于不确定为何有些医院的治疗结果比其他医院差，这些努力受到了限制。
利用2006 - 2007年国家癌症数据库的数据，我们根据膀胱癌、食管癌、结肠癌、肺癌、胰腺癌和胃癌手术后围手术期死亡率的综合指标，对1279家医院进行了排名。然后，我们对19家低死亡率（2.1%）医院或30家高死亡率（9.1%）医院中的5632例患者的病历进行了详细审查。采用分层逻辑回归分析比较发生严重并发症患者的风险调整后并发症发生率和病死率。
两组医院7.0%的绝对死亡率差异可归因于手术部位、肺部、血栓栓塞和其他并发症导致的较高死亡率。两组医院的总体并发症发生率没有差异[21.2%对17.8%；调整优势比（OR）= 1.34，95%置信区间（CI）：0.93 - 1.94]。相比之下，高死亡率医院并发症后的病死率比低死亡率医院高出三倍多（25.9%对13.6%；调整OR = 3.23，95% CI：1.56 - 6.69）。
低死亡率和高死亡率医院的区别不在于并发症发生率，而在于并发症后患者死亡的频率。确保及时识别和有效管理术后并发症的策略对于降低癌症手术后的死亡率至关重要。
