教学医院与非教学医院急诊普通外科手术后的结果。
Outcomes after emergency general surgery at teaching versus nonteaching hospitals.
作者信息
Zafar Syed Nabeel, Shah Adil A, Hashmi Zain G, Efron David T, Haut Elliott R, Schneider Eric B, Schwartz Diane, Velopulos Catherine G, Cornwell Edward E, Haider Adil H
机构信息
From the Department of Surgery (S.N.Z., E.E.C.), Howard University Hospital, Washington District of Columbia; Center for Surgical Trials and Outcomes Research (A.A.S., D.T.E., E.R.H., E.B.S., D.S., C.G.V.), Center for Surgery and Public Health Brigham Women's Hospital, Harvard Medical School and Harvard School of Public Health (A.H.H.), Department of Surgery, Johns Hopkins Medical Institute; and Department of Surgery (Z.G.H.), Sinai Hospital, Baltimore, Maryland.
出版信息
J Trauma Acute Care Surg. 2015 Jan;78(1):69-76; discussion 76-7. doi: 10.1097/TA.0000000000000493.
BACKGROUND
Previous analyses demonstrate teaching hospitals to have worse outcomes raising concerns for quality of care. The purpose of this study was to compare outcomes between teaching and nonteaching hospitals for emergency surgical conditions in a national sample.
METHODS
The Nationwide Inpatient Sample (2005-2011) was queried for patients with emergency general surgery (EGS) conditions as determined by the American Association for Surgery of Trauma. Outcomes of in-hospital mortality, major complications, length of stay (LOS) and hospital cost were compared between patients presenting to teaching versus nonteaching hospitals. Propensity scores were used to match both groups on demographics, clinical diagnosis, comorbidities, and disease severity. Multivariate regression analyses were performed further adjusting for hospital-level factors including EGS volume. Small effect estimates were further tested using standardized differences.
RESULTS
A total of 3,707,465 patients from 3,163 centers were included. A majority of patients (59%) (n = 2,187,107) were treated at nonteaching hospitals. After propensity score matching and adjustment, teaching hospitals had a slightly higher odds likelihood of mortality (odds ratio, 1.04; 95% confidence interval, 1.02-1.06), slightly lower rate of major complications (odds ratio, 0.99; 95% confidence interval, 0.98-0.99), slightly decreased LOS (5.03 days [4.98-5.09] vs. 5.22 days [5.16-5.29]), and slightly higher hospital costs [$12,846 [$12,827-$12,865] vs. $12,304 [12,290-12,318]). Although these differences were statistically significant at p < 0.05, the absolute difference was very small. Further testing of these effect estimates using standardized differences revealed an insignificant difference of 0.5% for mortality, 0.4% for major complications, 0.2% for LOS, and 3.1% for hospital cost.
CONCLUSION
National estimates of outcomes for EGS conditions demonstrate comparable results between teaching and nonteaching hospitals. Concerns regarding quality of care and higher costs at teaching hospitals may be unfounded. Further research to test for differences by specific EGS conditions, operative management, and hospital costs are warranted.
背景
以往分析表明，教学医院的治疗结果较差，引发了对医疗质量的担忧。本研究的目的是在全国样本中比较教学医院和非教学医院在急诊外科疾病方面的治疗结果。
方法
查询2005年至2011年的全国住院患者样本，以获取由美国创伤外科学会确定的急诊普通外科（EGS）疾病患者。比较前往教学医院和非教学医院的患者的院内死亡率、主要并发症、住院时间（LOS）和医院费用等结果。使用倾向评分在人口统计学、临床诊断、合并症和疾病严重程度方面对两组进行匹配。进行多变量回归分析，进一步调整包括EGS手术量在内的医院层面因素。使用标准化差异对小效应估计值进行进一步检验。
结果
纳入了来自3163个中心的3707465例患者。大多数患者（59%）（n = 2187107）在非教学医院接受治疗。经过倾向评分匹配和调整后，教学医院的死亡几率略高（优势比，1.04；95%置信区间，1.02 - 1.06），主要并发症发生率略低（优势比，0.99；95%置信区间，0.98 - 0.99），住院时间略有缩短（5.03天[4.98 - 5.09]对5.22天[5.16 - 5.29]），医院费用略高（12846美元[12827 - 12865美元]对12304美元[12290 - 12318美元]）。尽管这些差异在p < 0.05时具有统计学意义，但绝对差异非常小。使用标准化差异对这些效应估计值进行进一步检验显示，死亡率差异为0.5%，主要并发症差异为0.4%，住院时间差异为0.2%，医院费用差异为3.1%，均无显著差异。
结论
全国范围内EGS疾病治疗结果的估计表明，教学医院和非教学医院的结果相当。对教学医院医疗质量和更高成本的担忧可能没有根据。有必要进一步研究按特定EGS疾病、手术管理和医院费用进行的差异检验。
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