Adam Mohamed Abdelgadir, Thomas Samantha, Youngwirth Linda, Hyslop Terry, Reed Shelby D, Scheri Randall P, Roman Sanziana A, Sosa Julie A
*Department of Surgery, Duke University Medical Center, Durham, NC †Department of Biostatistics, Duke University, Durham, NC ‡Duke Clinical Research Institute, Durham, NC.
Ann Surg. 2017 Feb;265(2):402-407. doi: 10.1097/SLA.0000000000001688.
To determine the number of total thyroidectomies per surgeon per year associated with the lowest risk of complications.
The surgeon volume-outcome association has been established for thyroidectomy; however, a threshold number of cases defining a "high-volume" surgeon remains unclear.
Adults undergoing total thyroidectomy were identified from the Health Care Utilization Project-National Inpatient Sample (1998-2009). Multivariate logistic regression with restricted cubic splines was utilized to examine the association between the number of annual total thyroidectomies per surgeon and risk of complications.
Among 16,954 patients undergoing total thyroidectomy, 47% had thyroid cancer and 53% benign disease. Median annual surgeon volume was 7 cases; 51% of surgeons performed 1 case/y. Overall, 6% of the patients experienced complications. After adjustment, the likelihood of experiencing a complication decreased with increasing surgeon volume up to 26 cases/y (P < 0.01). Among all patients, 81% had surgery by low-volume surgeons (≤25 cases/y). With adjustment, patients undergoing surgery by low-volume surgeons were more likely to experience complications (odds ratio 1.51, P = 0.002) and longer hospital stays (+12%, P = 0.006). Patients had an 87% increase in the odds of having a complication if the surgeon performed 1 case/y, 68% for 2 to 5 cases/y, 42% for 6 to 10 cases/y, 22% for 11 to 15 cases/y, 10% for 16 to 20 cases/y, and 3% for 21 to 25 cases/y.
This is the first study to identify a surgeon volume threshold (>25 total thyroidectomies/y) that is associated with improved patient outcomes. Identifying a threshold number of cases defining a high-volume thyroid surgeon is important, as it has implications for quality improvement, criteria for referral and reimbursement, and surgical education.
确定每年每位外科医生进行的全甲状腺切除术数量与最低并发症风险相关的数值。
甲状腺切除术中外科医生手术量与预后的关联已得到证实；然而，界定“高手术量”外科医生的病例数阈值仍不明确。
从医疗保健利用项目 - 全国住院患者样本（1998 - 2009年）中识别接受全甲状腺切除术的成年人。采用带有受限立方样条的多变量逻辑回归来检验每位外科医生每年全甲状腺切除术数量与并发症风险之间的关联。
在16954例接受全甲状腺切除术的患者中，47%患有甲状腺癌，53%为良性疾病。外科医生的年手术量中位数为7例；51%的外科医生每年进行1例手术。总体而言，6%的患者出现并发症。调整后，并发症发生的可能性随着外科医生手术量增加至每年26例而降低（P < 0.01）。在所有患者中，81%由低手术量外科医生（≤25例/年）进行手术。调整后，由低手术量外科医生进行手术的患者更有可能出现并发症（优势比1.51，P = 0.002）且住院时间更长（增加12%，P = 0.006）。如果外科医生每年进行1例手术，患者出现并发症的几率增加87%，每年进行2至5例手术增加68%，每年进行6至10例手术增加42%，每年进行11至15例手术增加22%，每年进行16至20例手术增加10%，每年进行21至25例手术增加3%。
这是第一项确定与改善患者预后相关的外科医生手术量阈值（每年>25例全甲状腺切除术）的研究。确定界定高手术量甲状腺外科医生的病例数阈值很重要，因为它对质量改进、转诊和报销标准以及外科教育都有影响。
