Schootman M, Lian M, Pruitt S L, Hendren S, Mutch M, Deshpande A D, Jeffe D B, Davidson N O
Department of Epidemiology, Saint Louis University, Saint Louis, MO, USA,
Ann Surg Oncol. 2014 Aug;21(8):2659-66. doi: 10.1245/s10434-013-3472-x. Epub 2014 Apr 21.
The purpose of this study was to describe hospital and geographic variation in 30-day risk of surgical complications and death among colorectal cancer (CRC) patients and the extent to which patient-, hospital-, and census-tract-level characteristics increased risk of these outcomes.
We included patients at least 66 years old with first primary stage I-III CRC from the 2000-2005 National Cancer Institute's Surveillance, Epidemiology, and End Results data linked with 1999-2005 Medicare claims. A multilevel, cross-classified logistic model was used to account for nesting of patients within hospitals and within residential census tracts. Outcomes were risk of complications and death after a complication within 30 days of surgery.
Data were analyzed for 35,946 patients undergoing surgery at 1,222 hospitals and residing in 12,187 census tracts; 27.2 % of patients developed complications, and of these 13.4 % died. Risk-adjusted variability in complications across hospitals and census tracts was similar. Variability in mortality was larger than variability in complications, across hospitals and across census tracts. Specific characteristics increased risk of complications (e.g., census-tract-poverty rate, emergency surgery, and being African-American). No hospital characteristics increased complication risk. Specific characteristics increased risk of death (e.g. census-tract-poverty rate, being diagnosed with colon (versus rectal) cancer, and emergency surgery), while hospitals with at least 500 beds showed reduced death risk.
Large, unexplained variations exist in mortality after surgical complications in CRC across hospitals and geographic areas. The potential exists for quality improvement efforts targeted at the hospital and/or census-tract levels to prevent complications and augment hospitals' ability to reduce mortality risk.
本研究旨在描述结直肠癌（CRC）患者手术并发症和死亡的30天风险的医院及地理差异，以及患者、医院和普查区层面的特征在多大程度上增加了这些不良后果的风险。
我们纳入了2000 - 2005年美国国立癌症研究所监测、流行病学和最终结果数据中至少66岁的I - III期原发性结直肠癌患者，并与1999 - 2005年医疗保险理赔数据相链接。采用多层次交叉分类逻辑模型来考虑患者在医院和居住普查区内的嵌套情况。结局指标为手术后30天内出现并发症及并发症后的死亡风险。
对1222家医院的35946例接受手术且居住在12187个普查区的患者数据进行了分析；27.2%的患者出现并发症，其中13.4%死亡。经风险调整后，医院和普查区之间并发症的变异性相似。死亡率的变异性在医院和普查区层面均大于并发症的变异性。特定特征增加了并发症风险（如普查区贫困率、急诊手术以及非裔美国人）。没有医院特征增加并发症风险。特定特征增加了死亡风险（如普查区贫困率、被诊断为结肠癌（而非直肠癌）以及急诊手术），而床位至少500张的医院显示死亡风险降低。
在结直肠癌手术并发症后的死亡率方面，医院和地理区域存在巨大的、无法解释的差异。针对医院和/或普查区层面进行质量改进努力以预防并发症并增强医院降低死亡风险的能力是有可能的。
