Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg Klinik für Allgemein- und Viszeralchirurgie Krankenhausstraße 12, Erlangen, Germany.
Technische Universität Berlin Department for Structural Advancement and Quality Management in Health Care Fraunhoferstr. 33-36, Berlin, Germany.
Ann Surg. 2018 Mar;267(3):411-417. doi: 10.1097/SLA.0000000000002248.
We aimed to determine the effect of hospital volume on in-hospital mortality, and failure to rescue following major pancreatic resections using hospital discharge data of every inpatient case in Germany.
Several studies have found strong volume-outcome relationships in pancreatic surgery, with high mortality in low-volume facilities. However, their datasets were only based on portions of national populations. In addition, these studies did not assess the effect of hospital volume according to other crucial variables such as medical indications, postoperative complications, and failure to rescue.
We studied all inpatient cases of major pancreatic surgery (n = 60,858) in Germany from 2009 to 2014, using national hospital discharge data. We evaluated the association between hospital volume and in-hospital mortality following major pancreatic resections by using multivariate regression methods. In addition, we analyzed rates of major complications and failure to rescue across hospital volume quintiles.
Risk-adjusted in-hospital mortality varied widely across hospital volume quintiles, from 6.5% (95% CI 6.0-7.0) in very high volume hospitals to 11.5% (95% CI 10.9-12.1) in very low volume hospitals (OR 0.47, 95% CI 0.41-0.54). Rates of postoperative interventions necessary for complications and failure to rescue were lower in higher volume hospitals [eg, mortality following septic complications in very high volume hospitals: 24.2% (95% CI 22.4-26.1) vs. very low volume hospitals: 36.8% (34.9-38.7)]. Moreover, we estimated that centralization of surgical care to the minimum volume and mortality risk of the medium volume quintile could prevent at least 94 deaths per year.
In Germany, patients who are undergoing major pancreatic resections have improved outcomes if they are admitted to higher volume hospitals. As current health policies failed to centralize pancreatic surgery procedures in Germany, new strategies to initiate a sufficient centralization process in the field of pancreatic surgery are needed.
我们旨在利用德国每位住院患者的出院数据，确定医院容量对主要胰腺切除术后院内死亡率和抢救失败的影响。
多项研究发现，胰腺外科手术存在较强的量效关系，低容量医疗机构的死亡率较高。然而，这些研究的数据集仅基于部分国家人群。此外，这些研究并未根据其他关键变量（如医疗指征、术后并发症和抢救失败）评估医院容量的影响。
我们使用国家住院患者数据，研究了 2009 年至 2014 年德国所有主要胰腺手术（n=60858）的住院病例。我们使用多变量回归方法评估了主要胰腺切除术后医院容量与院内死亡率之间的关系。此外，我们分析了不同医院容量五分位数之间的主要并发症和抢救失败的发生率。
风险调整后的院内死亡率在医院容量五分位数之间差异很大，从高容量医院的 6.5%（95%CI 6.0-7.0）到低容量医院的 11.5%（95%CI 10.9-12.1）（OR 0.47，95%CI 0.41-0.54）。高容量医院术后干预并发症和抢救失败的发生率较低[例如，高容量医院感染性并发症导致的死亡率：24.2%（95%CI 22.4-26.1）与低容量医院：36.8%（34.9-38.7）]。此外，我们估计，将手术治疗集中到最小容量和中等容量五分位数的最低死亡率，可以每年预防至少 94 例死亡。
在德国，接受主要胰腺切除术的患者如果入住高容量医院，其治疗效果会更好。由于当前的卫生政策未能将胰腺手术集中在德国，因此需要制定新的策略，在胰腺外科领域启动充分的集中化进程。
