甲状腺手术中术中神经监测使用情况的变化分析。
Analysis of Variations in the Use of Intraoperative Nerve Monitoring in Thyroid Surgery.
机构信息
Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana.
Division of Thyroid and Parathyroid Endocrine Surgery, Massachusetts Eye and Ear Infirmary, Boston.
出版信息
JAMA Otolaryngol Head Neck Surg. 2016 Jun 1;142(6):584-9. doi: 10.1001/jamaoto.2016.0412.
IMPORTANCE
Intraoperative nerve monitoring (IONM) is increasingly performed during thyroid surgery.
OBJECTIVE
To examine the use of IONM and its association with patient demographic characteristics and surgeon volume.
DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional analysis used the State Inpatient Databases from January 1, 2010, to December 31, 2011, to assess patient demographic characteristics and surgeon volume. Available 30-day readmission data for all adult patients (aged ≥18 years) who underwent thyroidectomy in Florida, New York, and Washington were included. Follow-up was completed on December 31, 2011, and data were analyzed from March 11, 2015, to February 17, 2016.
MAIN OUTCOMES AND MEASURES
Use of IONM and incidence of postoperative vocal cord paralysis.
RESULTS
A total of 17 268 patients undergoing thyroidectomy were included (20.3% men; 79.7% women; mean [SD] age, 53.0 [15.1] years), of whom 1433 patients (8.3%) had IONM. Patients who were significantly less likely to undergo IONM included black patients (185 [7.9%]; adjusted odds ratio [AOR], 0.79; 95% CI, 0.65-0.97) and those with Medicare (382 [8.4%]; AOR, 0.81; 95% CI, 0.69-0.94) or Medicaid (125 [5.5%]; AOR, 0.59; 95% CI, 0.48, 0.74) health coverage. Black patients had a higher prevalence of vocal cord paralysis compared with white patients (37 [1.6%] vs 138 [1.3%]; AOR, 1.64; 95% CI, 1.11-2.43) in a multivariate model that also controlled for IONM use. Low-volume surgeons were more likely to use IONM (1199 [9.2%] vs 234 [5.5%]; AOR, 1.76; 95% CI, 1.48-2.09). However, patients treated by low-volume surgeons had a higher risk for vocal cord paralysis compared with those treated by high-volume surgeons (187 [1.4%] vs 26 [0.6%]; AOR, 2.47; 95% CI, 1.61-3.80). The risk for vocal cord paralysis was not associated with the performance of IONM (AOR, 0.74; 95% CI, 0.48-1.16) or the type of thyroidectomy (AOR, 1.04; 95% CI, 0.75-1.44).
CONCLUSIONS AND RELEVANCE
Disparities in the use of IONM are based on demographic factors of the patients and surgeon volume. Intraoperative nerve monitoring appears to be used less in black patients or those with Medicare health coverage and is not associated with the risk for vocal cord paralysis.
重要性
术中神经监测（IONM）在甲状腺手术中越来越多地进行。
目的
检查 IONM 的使用情况及其与患者人口统计学特征和外科医生手术量的关系。
设计、设置和参与者：使用 2010 年 1 月 1 日至 2011 年 12 月 31 日的州住院患者数据库进行横断面分析，以评估患者的人口统计学特征和外科医生的手术量。纳入了所有在佛罗里达州、纽约州和华盛顿州接受甲状腺切除术的年龄≥18 岁的成年患者的 30 天内再入院数据。随访于 2011 年 12 月 31 日完成，数据分析于 2015 年 3 月 11 日至 2016 年 2 月 17 日进行。
主要结局和测量
IONM 的使用情况和术后声带麻痹的发生率。
结果
共纳入 17268 例接受甲状腺切除术的患者（20.3%为男性；79.7%为女性；平均[SD]年龄为 53.0[15.1]岁），其中 1433 例（8.3%）接受了 IONM。不太可能接受 IONM 的患者包括黑人患者（185 例[7.9%]；调整后的优势比[AOR]，0.79；95%CI，0.65-0.97）和 Medicare（382 例[8.4%]；AOR，0.81；95%CI，0.69-0.94）或 Medicaid（125 例[5.5%]；AOR，0.59；95%CI，0.48-0.74）医疗保险覆盖的患者。在多变量模型中，黑人患者声带麻痹的发生率高于白人患者（37 例[1.6%]比 138 例[1.3%]；AOR，1.64；95%CI，1.11-2.43），该模型还控制了 IONM 的使用情况。低手术量的外科医生更有可能使用 IONM（1199 例[9.2%]比 234 例[5.5%]；AOR，1.76；95%CI，1.48-2.09）。然而，与高手术量的外科医生相比，低手术量的外科医生的声带麻痹风险更高（187 例[1.4%]比 26 例[0.6%]；AOR，2.47；95%CI，1.61-3.80）。声带麻痹的风险与 IONM 的使用（AOR，0.74；95%CI，0.48-1.16）或甲状腺切除术的类型（AOR，1.04；95%CI，0.75-1.44）无关。
结论和相关性
IONM 使用的差异基于患者的人口统计学因素和外科医生的手术量。术中神经监测在黑人患者或 Medicare 医疗保险覆盖的患者中使用较少，且与声带麻痹的风险无关。
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