Buettner Stefan, Gani Faiz, Amini Neda, Spolverato Gaya, Kim Yuhree, Kilic Arman, Wagner Doris, Pawlik Timothy M
Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
Surgery. 2016 Apr;159(4):1004-12. doi: 10.1016/j.surg.2015.10.025. Epub 2015 Dec 2.
BACKGROUND: Although previous reports have focused on factors at the hospital level to explain variations in postoperative outcomes, less is known regarding the effect of provider-specific factors on postoperative outcomes such as failure-to-rescue (FTR) and postoperative mortality. The current study aimed to quantify the relative contributions of surgeon and hospital volume on the volume-outcomes relationship among a cohort of patients undergoing liver resection. METHODS: Patients undergoing liver surgery for cancer were identified using the Nationwide Inpatient Sample from 2001 and 2009. Multivariable logistic regression analysis was performed to identify factors associated with mortality and FTR. Point estimates were used to calculate the relative effects of hospital and surgeon volume on mortality and FTR. RESULTS: A total of 5,075 patients underwent liver surgery and met inclusion criteria. Median patient age was 62 years (interquartile range, 52-70) and 55.2% of patients were male. Mortality was lowest among patients treated at high-volume hospitals and among patients treated by high-volume surgeons (both P < .001). Similar patterns in FTR were noted relative to hospital and surgeon volume (hospital volume: low vs intermediate vs high; 10.3 vs 9.0 vs 5.2%; surgeon volume: low vs intermediate vs high, 11.1 vs 9.1 vs 4.1%; both P < .05). On multivariable analysis, compared with high-volume surgeons, lower volume surgeons demonstrated greater odds for mortality (intermediate: odds ratio [OR], 2.27 [95% CI, 1.27-4.06; P = .006]; low, OR, 2.83 [95% CI, 1.52-5.27; P = .001]), and FTR (intermediate: OR, 2.86 [95% CI, 1.53-5.34, P = .001]; low, OR, 3.40 [95% CI, 1.75-6.63; P < .001]). While hospital volume accounted for 0.5% of the surgeon volume effect on increased FTR for low-volume surgeons, surgeon volume accounted for nearly all of the hospital volume effect on increased FTR in low-volume hospitals. CONCLUSION: The risk of complications, mortality, and FTR were less among both high-volume hospitals and high-volume surgeons, but the beneficial effect of volume on outcomes was attributable largely to surgeon volume.
背景：尽管既往报告主要关注医院层面的因素以解释术后结局的差异，但对于术者特定因素对术后结局如未能挽救（FTR）和术后死亡率的影响知之甚少。本研究旨在量化外科医生手术量和医院手术量对一组肝切除患者手术量-结局关系的相对贡献。 方法：利用2001年和2009年全国住院患者样本确定接受肝癌肝手术的患者。进行多变量逻辑回归分析以确定与死亡率和FTR相关的因素。点估计用于计算医院和外科医生手术量对死亡率和FTR的相对影响。 结果：共有5075例患者接受肝手术并符合纳入标准。患者中位年龄为62岁（四分位间距，52 - 70岁），55.2%的患者为男性。高手术量医院治疗的患者和高手术量外科医生治疗的患者死亡率最低（均P < 0.001）。观察到FTR与医院和外科医生手术量存在相似模式（医院手术量：低 vs 中 vs 高；10.3% vs 9.0% vs 5.2%；外科医生手术量：低 vs 中 vs 高，11.1% vs 9.1% vs 4.1%；均P < 0.05）。多变量分析显示，与高手术量外科医生相比，低手术量外科医生的患者死亡率更高（中等手术量：比值比[OR]，2.27[95%CI，1.27 - 4.06；P = 0.006]；低手术量，OR，2.83[95%CI，1.52 - 5.27；P = 0.001]），FTR也更高（中等手术量：OR，2.86[95%CI，1.53 - 5.34，P = 0.001]；低手术量，OR，3.40[95%CI，1.75 - 6.63；P < 0.001]）。对于低手术量外科医生，医院手术量占其手术量增加导致FTR升高效应的0.5%，而对于低手术量医院，外科医生手术量几乎占医院手术量增加导致FTR升高效应的全部。 结论：高手术量医院和高手术量外科医生的并发症、死亡率和FTR风险均较低，但手术量对结局的有益影响主要归因于外科医生手术量。
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