Alali Aziz S, Gomez David, McCredie Victoria, Mainprize Todd G, Nathens Avery B
Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.
Division of Neurosurgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
Neurosurgery. 2017 Apr 1;80(4):534-542. doi: 10.1093/neuros/nyw098.
The hospital volume-outcome relationship in severe traumatic brain injury (TBI) population remains unclear.
To examine the relationship between volume of patients with severe TBI per hospital and in-hospital mortality, major complications, and mortality following a major complication (ie, failure to rescue).
In a multicenter cohort study, data on 9255 adults with severe TBI were derived from 111 hospitals participating in the American College of Surgeons Trauma Quality Improvement Program over 2009-2011. Hospitals were ranked into quartiles based on their volume of severe TBI during the study period. Random-intercept multilevel models were used to examine the association between hospital quartile of severe TBI volume and in-hospital mortality, major complications, and mortality following a major complication after adjusting for patient and hospital characteristics. In sensitivity analyses, we examined these associations after excluding transferred cases.
Overall mortality was 37.2% (n = 3447). Two thousand ninety-eight patients (22.7%) suffered from 1 or more major complication. Among patients with major complications, 27.8% (n = 583) died. Higher-volume hospitals were associated with lower mortality; the adjusted odds ratio of death was 0.50 (95% confidence interval: 0.29-0.85) in the highest volume quartile compared to the lowest. There was no significant association between hospital-volume quartile and the odds of a major complication or the odds of death following a major complication. After excluding transferred cases, similar results were found.
High-volume hospitals might be associated with lower in-hospital mortality following severe TBI. However, this mortality reduction was not associated with lower risk of major complications or death following a major complication.
严重创伤性脑损伤（TBI）患者群体中，医院规模与治疗结果的关系仍不明确。
探讨每家医院严重TBI患者数量与院内死亡率、主要并发症以及主要并发症后的死亡率（即抢救失败）之间的关系。
在一项多中心队列研究中，9255例成年严重TBI患者的数据来自2009年至2011年参与美国外科医师学会创伤质量改进项目的111家医院。根据研究期间严重TBI患者数量，将医院分为四分位数。采用随机截距多水平模型，在对患者和医院特征进行调整后，检验严重TBI患者数量的医院四分位数与院内死亡率、主要并发症以及主要并发症后的死亡率之间的关联。在敏感性分析中，我们排除转院病例后检验了这些关联。
总体死亡率为37.2%（n = 3447）。2098例患者（22.7%）发生1种或更多主要并发症。在发生主要并发症的患者中，27.8%（n = 583）死亡。患者数量较多的医院死亡率较低；与最低四分位数相比，最高四分位数的调整后死亡比值比为0.50（95%置信区间：0.29 - 0.85）。医院四分位数与主要并发症的发生几率或主要并发症后的死亡几率之间无显著关联。排除转院病例后，发现了类似结果。
患者数量较多的医院可能与严重TBI后的较低院内死亡率相关。然而，这种死亡率的降低与主要并发症风险较低或主要并发症后的死亡风险较低无关。
