O'Mahoney Paul R A, Yeo Heather L, Sedrakyan Art, Trencheva Koiana, Mao Jialin, Isaacs Abby J, Lieberman Michael D, Michelassi Fabrizio
Department of Surgery, NewYork-Presbyterian-Weill Cornell Medical College, New York, NY.
Department of Surgery, NewYork-Presbyterian-Weill Cornell Medical College, New York, NY; Department of Healthcare Policy and Research, NewYork-Presbyterian-Weill Cornell Medical College, New York, NY.
Surgery. 2016 Jun;159(6):1528-1538. doi: 10.1016/j.surg.2016.01.008. Epub 2016 Feb 17.
The hospital volume-outcome relationship for complex procedures has led to the suggestion that care should be centralized. This study was performed to investigate whether centralization is occurring for pancreatoduodenectomy (PD) and to examine its effect on short-term postoperative outcomes.
We queried the New York State Statewide Planning and Research Cooperative System database (n = 6,185, 2002-2011) and the California and Florida State Inpatient Databases (n = 6,766 and 4,810, respectively, 2002-2011) for PD. Hospitals were divided into low (≤10), medium (11-25), high (25-60), and very high (≥61) groups depending on annual volume. Hierarchical logistic modeling accounted for patient clustering within hospitals.
A migration of cases from low-volume to medium, high, and very high-volume (MHVH) hospitals occurred in these 3 states (P < .01). There was an increase in the number of MHVH hospitals and a decrease in the number of low-volume hospitals performing PD across all states over time, with a large number of hospitals ceasing to perform PD cases entirely. Comorbidities such as congestive heart failure and diabetes were more prevalent in low-volume hospitals. After we adjusted for all predictors, MHVH hospitals had less rates of mortality and morbidity and shorter durations of stay than low-volume hospitals (P < .05); 30-day readmission rates were similar across all volume groups.
Centralization of PD is occurring in these 3 states and probably across the nation. After PD, MHVH hospitals had statistically better outcomes (mortality, morbidity, and duration of stay) than low-volume hospitals. Readmission rates were not affected by volume.
复杂手术的医院手术量与治疗结果之间的关系引发了应将治疗集中化的建议。本研究旨在调查胰十二指肠切除术（PD）是否正在实现集中化，并探讨其对术后短期结果的影响。
我们查询了纽约州全州规划与研究合作系统数据库（2002 - 2011年，n = 6185）以及加利福尼亚州和佛罗里达州住院患者数据库（2002 - 2011年，分别为n = 6766和4810）中的PD病例。根据年手术量，医院被分为低（≤10例）、中（11 - 25例）、高（25 - 60例）和极高（≥61例）组。分层逻辑模型考虑了医院内患者的聚类情况。
这三个州出现了病例从低手术量医院向中、高和极高手术量（MHVH）医院的转移（P <.01）。随着时间推移，所有州进行PD手术的MHVH医院数量增加，低手术量医院数量减少，大量医院完全停止进行PD手术。充血性心力衰竭和糖尿病等合并症在低手术量医院更为普遍。在对所有预测因素进行调整后，MHVH医院的死亡率和发病率较低，住院时间较短，与低手术量医院相比有差异（P <.05）；所有手术量组的30天再入院率相似。
这三个州以及可能在全国范围内都在发生PD手术的集中化。PD手术后，MHVH医院在统计学上的结果（死亡率、发病率和住院时间）优于低手术量医院。再入院率不受手术量影响。
