Wang Hsin-Hsiao S, Tejwani Rohit, Zhang Haijing, Wiener John S, Routh Jonathan C
Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina.
Duke University School of Medicine, Durham, North Carolina.
J Urol. 2015 Aug;194(2):506-11. doi: 10.1016/j.juro.2015.01.096. Epub 2015 Jan 29.
Hospital and provider surgical volume have been increasingly linked to surgical outcomes. However, this topic has rarely been addressed in children. We investigated whether hospital surgical volume impacts complication rates in pediatric urology.
We retrospectively reviewed the Nationwide Inpatient Sample (1998 to 2011) for pediatric (18 years or younger) hospitalizations for urological procedures. We used ICD-9-CM codes to identify elective urological interventions and NSQIP® postoperative in hospital complications. Annual hospital surgical volume was calculated and dichotomized as high volume (90th percentile or above) or non-high volume (below 90th percentile).
We identified 158,805 urological admissions (114,634 high volume and 44,171 non-high volume hospitals). Of the hospitals 75% recorded fewer than 5 major pediatric urology cases performed yearly. High volume hospitals showed treatment of significantly younger patients (mean 5.4 vs 9.6 years, p < 0.001) and were more likely to be teaching hospitals (93% vs 71%, p < 0.001). The overall rate of NSQIP identified postoperative complications was higher at non-high volume vs high volume hospitals (11.6% vs 9.3%, p = 0.003). After adjusting for confounding effects patients treated at non-high volume hospitals remained more likely to suffer multiple NSQIP tracked postoperative complications, including acute renal failure (OR 1.4, p = 0.04), urinary tract infection (OR 1.3, p = 0.01), postoperative respiratory complications (OR 1.5, p = 0.01), systemic sepsis (OR 2.0, p ≤ 0.001), postoperative bleeding (OR 2.5, p < 0.001) and in hospital death (OR 2.2, p = 0.007).
Urological procedures performed in children at non-high volume hospitals were associated with an increased risk of in hospital, NSQIP identified postoperative complications, including a small but significant increase in postoperative mortality, mostly following nephrectomy and percutaneous nephrolithotomy.
医院及医疗服务提供者的手术量与手术结果的关联日益受到关注。然而，这一话题在儿童患者中鲜有涉及。我们调查了医院手术量是否会影响小儿泌尿外科手术的并发症发生率。
我们回顾性分析了全国住院患者样本（1998年至2011年）中18岁及以下儿童因泌尿外科手术而住院的情况。我们使用ICD-9-CM编码来识别择期泌尿外科手术及美国国立外科手术质量改进项目（NSQIP®）所记录的术后院内并发症。计算各医院每年的手术量，并将其分为高手术量（第90百分位数及以上）或非高手术量（低于第90百分位数）。
我们共识别出158,805例泌尿外科住院病例（114,634例来自高手术量医院，44,171例来自非高手术量医院）。其中75%的医院每年进行的小儿泌尿外科大手术病例数少于5例。高手术量医院收治的患者明显更年幼（平均年龄5.4岁对9.6岁，p < 0.001），且更有可能是教学医院（93%对71%，p < 0.001）。NSQIP所识别的术后并发症总体发生率在非高手术量医院高于高手术量医院（11.6%对9.3%，p = 0.003）。在对混杂因素进行校正后，非高手术量医院的患者仍更有可能发生多种NSQIP所追踪的术后并发症，包括急性肾衰竭（比值比1.4，p = 0.04）、尿路感染（比值比1.3，p = 0.01）、术后呼吸并发症（比值比1.5，p = 0.01）、全身性脓毒症（比值比2.0，p ≤ 0.001）、术后出血（比值比2.5，p < 0.001）及院内死亡（比值比2.2，p = 0.007）。
在非高手术量医院接受泌尿外科手术的儿童患者，发生NSQIP所识别的术后院内并发症的风险增加，包括术后死亡率虽小但有显著升高，这主要发生在肾切除术和经皮肾镜取石术后。
