Shakeel Saad, Elit Laurie, Akhtar-Danesh Noori, Schneider Laura, Finley Christian
Department of Surgery, St. Joseph's Healthcare, Hamilton, Hamilton ON.
Department of Obstetrics and Gynecology, McMaster University, Hamilton ON.
J Obstet Gynaecol Can. 2017 Jan;39(1):25-33. doi: 10.1016/j.jogc.2016.09.075. Epub 2016 Dec 10.
In this pan-Canadian study, we sought to elucidate the current state of surgical care for primary ovarian cancers and factors influencing selected short-term outcomes; these were in-hospital mortality (IHM), major complications (MCs), failure-to-rescue (FTR), and hospital length of stay (LOS).
We created a population cohort using inpatient admission records from the Canadian Institute of Health Information data set (2004-2012). Multilevel logistic regression and flexible parametric survival analyses, adjusted for hospital clustering effect, were conducted to determine the effect of patient-specific factors (i.e., age, comorbidities, and admission category); procedural complexity; and the surgical volume and specialty of each care provider on the outcomes of interest.
A total of 16 089 women underwent surgeries for primary ovarian cancer across Canada. The crude rates of IHM, MC, and FTR were 0.89%, 5.7%, and 9.09%, respectively, with a median LOS of four days (interquartile range 3 to 6). The majority of surgical procedures were performed by surgeons and hospitals with annual surgical volumes of less than five such procedures. Hospitals with higher surgical volumes were associated with lower risk of IHM (OR 0.95, 95% CI 0.91 to 0.99) and FTR (OR 0.95, 95% CI 0.91 to 0.99) and a higher chance of earlier discharge (hazard ratio [HR] 1.03, 95% CI 1.00 to 1.06). Surgeons with higher surgical volumes were associated with lower odds of early discharge (HR 0.90, 95% CI 0.87 to 0.94) and a higher risk of MC (OR 1.12, 95% CI 1.02 to 1.23). Compared with gynaecologic oncologists, general surgeons had a significantly higher risk of IHM (OR 3.50, 95% CI 1.82 to 6.74) and MC (OR 2.13, 95% CI 1.36 to 3.33) and lower odds of early discharge (HR 0.43, 95% CI 0.40 to 0.47).
Despite limitations in the administrative data set, valuable information was available for this pan-Canadian analysis. Our findings support centralization of surgical procedures for women with ovarian cancer in tertiary care centres with higher surgical volumes that are staffed by in-house multidisciplinary care teams and specialist surgeons.
在这项全加拿大范围的研究中，我们试图阐明原发性卵巢癌外科治疗的现状以及影响某些短期结局的因素；这些结局包括住院死亡率（IHM）、主要并发症（MCs）、未能挽救（FTR）和住院时间（LOS）。
我们利用加拿大卫生信息研究所数据集（2004 - 2012年）中的住院患者入院记录创建了一个人群队列。进行了多水平逻辑回归和灵活参数生存分析，并对医院聚类效应进行了调整，以确定患者特异性因素（即年龄、合并症和入院类别）、手术复杂性以及每个医疗服务提供者的手术量和专业对感兴趣结局的影响。
加拿大共有16089名女性接受了原发性卵巢癌手术。IHM、MC和FTR的粗发生率分别为0.89%、5.7%和9.09%，中位住院时间为4天（四分位间距3至6天）。大多数手术由年手术量少于5例此类手术的外科医生和医院进行。手术量较高的医院与较低的IHM风险（比值比[OR]0.95，95%置信区间[CI]0.91至0.99）和FTR风险（OR 0.95，95% CI 0.91至0.99）以及更早出院的更高可能性（风险比[HR]1.03，95% CI 1.00至1.06）相关。手术量较高的外科医生与更早出院的较低几率（HR 0.90，95% CI 0.87至0.94）和更高的MC风险（OR 1.12，95% CI 1.02至1.23）相关。与妇科肿瘤学家相比，普通外科医生的IHM风险（OR 3.50，95% CI 1.82至6.74）和MC风险（OR 2.13，95% CI 1.36至3.33）显著更高，且更早出院的几率更低（HR 0.43，95% CI 0.40至0.47）。
尽管行政数据集存在局限性，但该全加拿大范围的分析仍可获得有价值的信息。我们的研究结果支持将卵巢癌女性的手术集中在三级医疗中心进行，这些中心手术量较高，配备内部多学科护理团队和专科外科医生。
