Ogola Gerald O, Haider Adil, Shafi Shahid
From the Center for Clinical Effectiveness, Office of the Chief Quality Officer (G.O.G., S.S.), Baylor Scott & White Health, Dallas, TX; and Center for Surgery and Public Health, Department of Surgery (A.H.), Brigham and Women's Hospital, Boston, MA.
J Trauma Acute Care Surg. 2017 Mar;82(3):497-504. doi: 10.1097/TA.0000000000001355.
Higher volume has been associated with lower mortality for several surgical diseases. It is not known if this relationship exists in the management of Emergency General Surgery (EGS). Our hypothesis was that EGS patients treated at hospitals with higher EGS volume experienced lower mortality rates than those treated at low-volume hospitals.
This was a retrospective analysis of 2010 National Inpatient Sample data, maintained by the Agency for Healthcare Quality and Research as a representative national sample of inpatients. Patients with EGS diseases were identified using American Association for the Surgery of Trauma definitions using ICD-9 codes (2,640,725 patients from 943 hospitals). Multivariable hierarchical logistic regression model was used to estimate the risk-standardized mortality rate (RSMR) for each hospital, adjusted for patient (age, sex, race, ethnicity, insurance type, socioeconomic status, comorbidities) and hospital (region, location, bed size, teaching status, ownership) characteristics. A cubic spline regression model with 4 knots was used to identify the volume associated with low mortality rates.
The volume of EGS patients treated was inversely associated with hospital mortality rate. RSMR in hospitals in the highest quintile of volume (median, 7424 patients) was 1.62% (95% CI: 1.61-1.64%); at hospitals in the lowest quintile of volume (median, 68 patients), it was 6.1% (95% CI: 6.0-6.2%) (p < 0.0001). Mortality rate stabilized at an annual volume of 688 (95% CI: 554-753) patients. The mortality rate in hospitals that treated fewer than 688 patients was 5.0% (95% CI: 4.8-5.1%), compared to 1.99% (95% CI: 1.96-2.01%) at those that treated 688 or more patients (p < 0.0001).
EGS patients treated at hospitals with a higher volume of EGS patients experienced lower mortality rates, with a possible threshold of 688 patients per year. A regionalized system of EGS care where complex patients are treated at large-volume centers may improve patient outcomes.
Therapeutic study, level III.
对于几种外科疾病，手术量越高与死亡率越低相关。目前尚不清楚这种关系在急诊普通外科（EGS）治疗中是否存在。我们的假设是，在EGS手术量较高的医院接受治疗的EGS患者比在手术量较低的医院接受治疗的患者死亡率更低。
这是一项对2010年国家住院患者样本数据的回顾性分析，该数据由医疗保健质量和研究机构保存，作为全国住院患者的代表性样本。使用美国创伤外科协会的定义和ICD - 9编码识别患有EGS疾病的患者（来自943家医院的2640725名患者）。多变量分层逻辑回归模型用于估计每家医院的风险标准化死亡率（RSMR），并根据患者（年龄、性别、种族、民族、保险类型、社会经济地位、合并症）和医院（地区、位置、床位规模、教学状况、所有权）特征进行调整。使用具有4个节点的三次样条回归模型来确定与低死亡率相关的手术量。
接受治疗的EGS患者手术量与医院死亡率呈负相关。手术量最高的五分之一医院（中位数为7424名患者）的RSMR为1.62%（95%可信区间：1.61 - 1.64%）；手术量最低的五分之一医院（中位数为68名患者）的RSMR为6.1%（95%可信区间：6.0 - 6.2%）（p < 0.0001）。死亡率在年手术量为688例（95%可信区间：554 - 753）患者时趋于稳定。治疗患者少于688例的医院死亡率为5.0%（95%可信区间：4.8 - 5.1%），而治疗688例或更多患者的医院死亡率为1.99%（95%可信区间：1.96 - 2.01%）（p < 0.0001）。
在EGS患者手术量较高的医院接受治疗的EGS患者死亡率较低，每年可能的阈值为688例患者。建立一个将复杂患者集中在大容量中心治疗的区域化EGS护理系统可能会改善患者的治疗效果。
治疗性研究，III级。
