Sammon Jesse D, Pucheril Daniel, Abdollah Firas, Varda Briony, Sood Akshay, Bhojani Naeem, Chang Steven L, Kim Simon P, Ruhotina Nedim, Schmid Marianne, Sun Maxine, Kibel Adam S, Menon Mani, Semel Marcus E, Trinh Quoc-Dien
Vattikuti Urology Institute, Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA.
BJU Int. 2015 Apr;115(4):666-74. doi: 10.1111/bju.12833. Epub 2014 Aug 19.
To assess in-hospital mortality in patients undergoing many commonly performed urological surgeries in light of decreasing nationwide perioperative mortality over the past decade. This phenomenon has been attributed in part to a decline in 'failure to rescue' (FTR) rates, e.g. death after a complication that was potentially recognisable/preventable.
Discharges of all patients undergoing urological surgery between 1998 and 2010 were extracted from the Nationwide Inpatient Sample and assessed for overall and FTR mortality. Admission trends were assessed with linear regression. Logistic regression models fitted with generalised estimating equations were used to estimate the impact of primary predictors on over-all and FTR mortality and changes in mortality rates.
Between 1998 and 2010, an estimated 7,725,736 urological surgeries requiring hospitalisation were performed in the USA; admissions for urological surgery decreased 0.63% per year (P = 0.008). Odds of overall mortality decreased slightly (odds ratio [OR] 0.990, 95% confidence interval [CI] 0.988-0.993), yet the odds of mortality attributable to FTR increased 5% every year (OR 1.050, 95% CI 1.038-1.062). Patient age, race, Charlson Comorbidity Index, public insurance status, as well as urban hospital location were independent predictors of FTR mortality (P < 0.001).
A shift from inpatient to outpatient surgery for commonly performed urological procedures has coincided with increasing rates of FTR mortality. Older, sicker, minority group patients and those with public insurance were more likely to die after a potentially recognisable/preventable complication. These strata of high-risk individuals represent ideal targets for process improvement initiatives.
鉴于过去十年全国围手术期死亡率下降，评估接受多种常见泌尿外科手术患者的院内死亡率。这种现象部分归因于“未能挽救”（FTR）率的下降，例如在可识别/可预防的并发症后死亡。
从全国住院患者样本中提取1998年至2010年间所有接受泌尿外科手术患者的出院信息，并评估总体死亡率和FTR死亡率。采用线性回归评估入院趋势。使用拟合广义估计方程的逻辑回归模型来估计主要预测因素对总体死亡率和FTR死亡率以及死亡率变化的影响。
1998年至2010年间，美国估计有7,725,736例需要住院治疗的泌尿外科手术；泌尿外科手术入院人数每年下降0.63%（P = 0.008）。总体死亡率的比值比略有下降（比值比[OR] 0.990，95%置信区间[CI] 0.988 - 0.993），但FTR导致的死亡比值比每年增加5%（OR 1.050，95% CI 1.038 - 1.062）。患者年龄、种族、查尔森合并症指数、公共保险状况以及城市医院位置是FTR死亡率的独立预测因素（P < 0.001）。
常见泌尿外科手术从住院手术向门诊手术的转变与FTR死亡率上升同时发生。年龄较大、病情较重、少数群体患者以及有公共保险的患者在出现可识别/可预防的并发症后更有可能死亡。这些高危个体阶层是流程改进举措的理想目标。
