Swiatek Peter R, Pandit Anita, Chung Kevin C, Mahmoudi Elham
Ann Arbor, Mich.
From the Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, and the University of Michigan School of Public Health.
Plast Reconstr Surg. 2016 Jul;138(1):141-151. doi: 10.1097/PRS.0000000000002287.
Traumatic digit amputations are prevalent injuries that have long-term disabling consequences. Although replantation after traumatic digit amputation is a complex procedure, the aesthetic, functional, and long-term economic benefits of replantation render it preferable to revision amputation when clinically indicated. The authors adapted the Donabedian quality-of-care conceptual framework to examine the association between hospital outcome quality measured by observed-to-expected mortality ratio and the treatment received after traumatic digit amputation. The authors hypothesized that the probability of undergoing replantation is higher in hospitals with lower observed-to-expected mortality ratios.
Data from 106 qualified Level I and II trauma centers included in the 2007 to 2012 National Trauma Data Bank were used to estimate hospital-specific observed-to-expected mortality ratio. The authors then used a two-level logistic hierarchical model, adjusting for patient, clinical, and hospital characteristics, to examine whether observed-to-expected mortality ratio, as one of the commonly used hospital quality measures, is a predictor of the treatment received for 4169 patients with traumatic digit amputation.
Compared with trauma centers with high observed-to-expected mortality ratios, the probability of undergoing replantation was substantially higher in trauma centers with low observed-to-expected mortality ratios (OR, 5.09; 95 percent CI, 2.51 to 10.30; p < 0.001). Seeking care at hospitals with more than 400 beds increased the probability of digit replantation (OR, 2.08; 95 percent CI, 1.08 to 4.01; p = 0.029). Having no insurance decreased the odds of undergoing replantation (OR, 0.70; 95 percent CI, 0.53 to 0.91; p = 0.009).
Hospital observed-to-expected mortality ratio was the greatest predictor of undergoing replantation after digit amputation injury. The observed-to-expected mortality ratio, as an outcome measure of hospital quality, is an important predictor of the treatment received.
创伤性断指是常见的损伤，会导致长期的致残后果。尽管创伤性断指再植是一个复杂的手术，但再植在美学、功能和长期经济方面的益处表明，在临床指征明确时，再植优于截肢修正术。作者采用唐纳贝迪安医疗质量概念框架，以观察到的死亡率与预期死亡率之比衡量的医院结局质量与创伤性断指截肢后接受的治疗之间的关联。作者假设，观察到的死亡率与预期死亡率之比更低的医院进行再植的概率更高。
利用2007年至2012年国家创伤数据库中纳入的106家合格的一级和二级创伤中心的数据，估算各医院的观察到的死亡率与预期死亡率之比。然后，作者使用两级逻辑分层模型，对患者、临床和医院特征进行调整，以检验观察到的死亡率与预期死亡率之比作为常用的医院质量指标之一，是否是4169例创伤性断指截肢患者接受治疗的预测因素。
与观察到的死亡率与预期死亡率之比高的创伤中心相比，观察到的死亡率与预期死亡率之比低的创伤中心进行再植的概率显著更高（比值比，5.09；95%可信区间，2.51至10.30；p<0.001）。在床位超过400张的医院就医会增加断指再植的概率（比值比，2.08；95%可信区间，1.08至4.01；p = 0.029）。没有保险会降低进行再植的几率（比值比，0.70；95%可信区间，0.53至0.91；p = 0.009）。
医院观察到的死亡率与预期死亡率之比是断指截肢损伤后进行再植的最大预测因素。观察到的死亡率与预期死亡率之比作为医院质量的一项结局指标，是接受治疗的重要预测因素。
