McNeely Christian, Markwell Stephen, Filson Kathryn, Hazelrigg Stephen, Vassileva Christina
Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois.
Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois.
Ann Thorac Surg. 2016 Feb;101(2):585-90. doi: 10.1016/j.athoracsur.2015.07.010. Epub 2015 Oct 1.
This study was designed to examine the effect of hospital procedural volume on outcomes in aortic valve replacement (AVR) in the elderly.
The study included 277,928 Medicare beneficiaries who underwent AVR from 2000 through 2009 at one of 1,255 participating hospitals. Operative mortality and the use of mechanical prostheses were analyzed according to hospital annual procedural volume. Annual AVR volume was divided into 5 different categories: the smallest volume group with less than 10 AVRs per year to the largest group averaging more than 70 AVRs per year.
The overall observed operative mortality rate was 7.3%; for isolated AVR it was 5.5%. Lower-volume hospitals exhibited increased adjusted operative mortality: 10 cases or fewer per year--odds ratio (OR), 1.55; 95% confidence interval (CI), 1.39 to 1.72; 11 to 20 cases per year--OR, 1.35; 95% CI, 1.23 to 1.47; 21 to 40 cases per year--OR, 1.15; 95% CI, 1.06 to 1.25; 41 to 70 cases per year--OR, 1.10; 95% CI, 1.01 to 1.20 relative to those hospitals performing more than 70 cases per year. The discrepancy in operative mortality between low- and high-volume hospitals diverged during the study. Mechanical valve use decreased with increasing hospital volume (p = 0.0001). Mechanical valves were used in 64.5% of AVRs in hospitals with an annual AVR volume less than 10 in contrast to only 25.4% in hospitals with an annual AVR volume more than 70. After adjustment, the use of mechanical valves was independently associated with increased operative mortality (OR, 1.15; 95% CI, 1.11-1.19).
Low-volume centers were characterized by increased adjusted operative mortality and greater use of mechanical prostheses, a trend that persisted during the 10-year course of the study. These data would support the center-of-excellence concept for AVR and may be particularly relevant in the elderly population.
本研究旨在探讨医院手术量对老年患者主动脉瓣置换术（AVR）预后的影响。
该研究纳入了277928名医疗保险受益患者，这些患者于2000年至2009年期间在1255家参与研究的医院之一接受了AVR手术。根据医院年度手术量分析手术死亡率和机械瓣膜的使用情况。年度AVR手术量分为5个不同类别：每年手术量最少的组，每年进行少于10例AVR手术；至手术量最大的组，平均每年超过70例AVR手术。
总体观察到的手术死亡率为7.3%；单纯AVR手术的死亡率为5.5%。手术量较低的医院调整后的手术死亡率有所增加：每年10例或更少——比值比（OR）为1.55；95%置信区间（CI）为1.39至1.72；每年11至20例——OR为1.35；95%CI为1.23至1.47；每年21至40例——OR为1.15；95%CI为1.06至1.25；每年41至70例——OR为1.10；95%CI为1.01至1.20，与每年进行超过70例手术的医院相比。在研究期间，手术量低和高的医院之间手术死亡率的差异逐渐增大。机械瓣膜的使用随着医院手术量的增加而减少（p = 0.0001）。年度AVR手术量少于10例的医院中，64.5%的AVR手术使用了机械瓣膜，而年度AVR手术量超过70例的医院中这一比例仅为25.4%。调整后，机械瓣膜的使用与手术死亡率增加独立相关（OR为1.15；95%CI为1.11 - 1.19）。
手术量低的中心特点是调整后的手术死亡率增加以及机械瓣膜使用更多，这一趋势在为期10年的研究过程中持续存在。这些数据支持AVR的卓越中心概念，并且可能在老年人群中尤为相关。
