Kalfa David, Chai Paul, Bacha Emile
Pediatric Cardiac Surgery, Columbia University Medical Center, Morgan Stanley Children's Hospital of New York-Presbyterian, 3959 Broadway, New York, NY, 10032, USA,
Pediatr Cardiol. 2014 Aug;35(6):899-905. doi: 10.1007/s00246-014-0938-y. Epub 2014 Jun 4.
A significant inverse relationship of surgical institutional and surgeon volumes to outcome has been demonstrated in many high-stakes surgical specialties. By and large, the same results were found in pediatric cardiac surgery, for which a more thorough analysis has shown that this relationship depends on case complexity and type of surgical procedures. Lower-volume programs tend to underperform larger-volume programs as case complexity increases. High-volume pediatric cardiac surgeons also tend to have better results than low-volume surgeons, especially at the more complex end of the surgery spectrum (e.g., the Norwood procedure). Nevertheless, this trend for lower mortality rates at larger centers is not universal. All larger programs do not perform better than all smaller programs. Moreover, surgical volume seems to account for only a small proportion of the overall between-center variation in outcome. Intraoperative technical performance is one of the most important parts, if not the most important part, of the therapeutic process and a critical component of postoperative outcome. Thus, the use of center-specific, risk-adjusted outcome as a tool for quality assessment together with monitoring of technical performance using a specific score may be more reliable than relying on volume alone. However, the relationship between surgical volume and outcome in pediatric cardiac surgery is strong enough that it ought to support adapted and well-balanced health care strategies that take advantage of the positive influence that higher center and surgeon volumes have on outcome.
在许多高风险外科专科中，手术机构和外科医生的手术量与手术结果之间存在显著的负相关关系。总体而言，小儿心脏外科也得出了相同的结果，对此进行的更深入分析表明，这种关系取决于病例的复杂性和手术程序的类型。随着病例复杂性的增加，手术量较低的机构往往表现不如手术量较大的机构。手术量高的小儿心脏外科医生的手术结果也往往优于手术量低的医生，尤其是在手术谱中较复杂的一端（例如诺伍德手术）。然而，大型中心死亡率较低的这种趋势并非普遍存在。并非所有大型机构都比所有小型机构表现更好。此外，手术量似乎仅占中心间总体结果差异的一小部分。术中技术操作是治疗过程中最重要的部分之一（即便不是最重要的部分），也是术后结果的关键组成部分。因此，将特定中心的、经过风险调整的结果用作质量评估工具，并使用特定评分监测技术操作，可能比仅依赖手术量更可靠。然而，小儿心脏外科手术量与结果之间的关系足够紧密，应该支持适应性强且平衡良好的医疗保健策略，这些策略利用了较高的中心和外科医生手术量对结果产生的积极影响。
