儿科脾脏管理的趋势：医院类型和所有权仍然重要吗？

Trends in pediatric spleen management: Do hospital type and ownership still matter?

作者信息

Liu Shaoming, Bowman Stephen M, Smith Tyler C, Sharar Sam R

机构信息

From the Department of Community Health (S.L., T.C.S.), School of Health and Human Services, National University, San Diego, California; Department of Health Policy and Management (S.M.B.), Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and Department of Anesthesiology (S.R.S.), School of Medicine, University of Washington, Seattle, Washington.

出版信息

J Trauma Acute Care Surg. 2015 May;78(5):935-42. doi: 10.1097/TA.0000000000000621.

DOI:10.1097/TA.0000000000000621

PMID:25909412

Abstract

BACKGROUND

Nonoperative management of traumatic blunt splenic injury is preferred over splenectomy because of improved outcomes and reduced complications. However, variability in treatment is previously reported with respect to hospital profit types and ownership.

METHODS

Our study objectives were to investigate the past decade's trends in pediatric splenic injury management and to determine whether previously reported disparities by hospital type have changed. We analyzed data from the Kid's Inpatient Database from Healthcare Cost and Utility Project for Years 2000, 2003, 2006, and 2009. Multivariable logistic regression was used to investigate the likelihood of receiving splenectomy in different hospital profit and ownership types. Patients 18 years and younger admitted with blunt splenic injury (DRG International Classification of Diseases-9th Rev.-Clinical Modification code 865) were included. Treatment was dichotomized into nonoperative management, defined as initial attempt at nonoperative management, and operative management, defined as splenectomy within 1 day of admission.

RESULTS

Of 17,044 patient records, 11,893 participants were studied. Not-for-profit hospitals demonstrated a higher rate of nonoperative management than for-profit hospitals in 2000 (83.8% vs. 71.0 %). Both not-for-profit and for-profit hospitals increased the use of nonoperative management, with a narrower disparity observed by 2009 (87.5% vs. 84.6%). The use of splenectomy was reduced significantly between 2000 and 2003 (odds ratio, 0.66; weighted 95% confidence interval, 0.54-0.81). The rate of nonoperative management in children's hospitals remained very high across the study period (98.6% in 2009) and continued to be the benchmark for pediatric spleen injury management.

CONCLUSION

Improvement was observed in nonoperative management rates for pediatric spleen injuries in both not-for-profit and for-profit hospitals. However, general hospitals still fail to reach the target of 90% nonoperative management. Further investigations are needed to facilitate optimal management of such children in general hospitals.

LEVELS OF EVIDENCE

Epidemiologic and prognostic study, level III.

摘要

背景

由于创伤性钝性脾损伤的非手术治疗能改善预后并减少并发症，因此相较于脾切除术，它更受青睐。然而，先前有报道称，在医院盈利类型和所有制方面，治疗存在差异。

方法

我们的研究目的是调查过去十年小儿脾损伤治疗的趋势，并确定先前报道的不同医院类型之间的差异是否有所变化。我们分析了来自医疗成本与效用项目的儿童住院数据库中2000年、2003年、2006年和2009年的数据。采用多变量逻辑回归分析不同医院盈利和所有制类型下接受脾切除术的可能性。纳入18岁及以下因钝性脾损伤入院的患者（疾病诊断相关分组国际疾病分类第9版临床修订版代码865）。治疗分为非手术治疗（定义为初次尝试非手术治疗）和手术治疗（定义为入院1天内进行脾切除术）。

结果

在17044份患者记录中，对11893名参与者进行了研究。2000年，非营利性医院的非手术治疗率高于营利性医院（83.8%对71.0%）。非营利性医院和营利性医院都增加了非手术治疗的使用，到2009年，两者之间的差距缩小（87.5%对84.6%）。2000年至2003年间，脾切除术的使用率显著降低（比值比，0.66；加权95%置信区间，0.54 - 0.81）。在整个研究期间，儿童医院的非手术治疗率一直很高（2009年为98.6%），并且仍然是小儿脾损伤治疗的基准。