Meltzer Andrew J, Agrusa Christopher, Connolly Peter H, Schneider Darren B, Sedrakyan Art
Division of Vascular Surgery, Weill Cornell Medical College, New York, NY.
Division of Vascular Surgery, Weill Cornell Medical College, New York, NY.
Ann Vasc Surg. 2017 Nov;45:56-61. doi: 10.1016/j.avsg.2017.05.015. Epub 2017 May 31.
The purpose of this study is to explore the impact of surgeon characteristics (including annual volume, specialty, and years in practice) on outcomes of carotid endarterectomy (CEA) for asymptomatic carotid atherosclerosis in New York State.
The New York Statewide Planning and Cooperation System database was utilized to identify patients undergoing CEA from 2004 to 2011. Provider characteristics were determined by linkage to the New York Office of Professions and National Provider Identification databases. Provider-level factors were characterized by defining 5 quintiles of equal size for each factor. Hierarchical logistic regression models were created to evaluate the impact of provider characteristics on outcome.
In total, 36,495 patients underwent CEA for asymptomatic disease performed by vascular (75.7%), general (16.1%), cardiac (6%), and neuro (2.1%) surgeons. Outcomes of interest included in-hospital mortality (0.26%), stroke (0.45%), and the composite end point of mortality, stroke, or cardiac complication (2.2%). Unadjusted outcomes improved with increasing surgeon annual CEA volume. Mid-career surgeons had lower mortality and stroke rates than early or late-career surgeons. Odds of mortality were increased when surgery was performed by the lowest volume providers (quintile 1; 0-11 CEA/year) (odds ratio [OR] 2.62, 95% confidence interval [CI] 1.3-5.28) or a nonspecialty trained (general) surgeon (OR 1.64, 95% 1.01-2.67). After adjustment for all patient-level factors, provider volume remained an independent predictor of outcome, with significantly increased odds of mortality for volume quintile 1 (OR 2.57, 95% CI 1.27-5.23) and quintile 2 (12-22 CEA/year) (0.30%; OR 2.07, 95% CI 1-4.27) surgeons.
Adverse events after CEA for asymptomatic disease are comparatively rare. However, surgeon characteristics impact outcome, with the best results offered by high-volume, mid-career, specialty-trained surgeons. Efforts to define the optimal treatment of asymptomatic carotid atherosclerosis must account for the impact of surgeon characteristics on patient outcomes.
本研究旨在探讨外科医生特征（包括年手术量、专业及从业年限）对纽约州无症状性颈动脉粥样硬化患者行颈动脉内膜切除术（CEA）预后的影响。
利用纽约州全州规划与合作系统数据库，确定2004年至2011年期间接受CEA手术的患者。通过与纽约职业办公室及国家医疗服务提供者识别数据库建立联系，确定医疗服务提供者的特征。通过为每个因素定义5个等规模的五分位数来描述医疗服务提供者层面的因素。建立分层逻辑回归模型，以评估医疗服务提供者特征对预后的影响。
共有36495例无症状性疾病患者接受了CEA手术，手术医生包括血管外科医生（75.7%）、普通外科医生（16.1%）、心脏外科医生（6%）和神经外科医生（2.1%）。关注的预后指标包括住院死亡率（0.26%）、卒中发生率（0.45%）以及死亡、卒中或心脏并发症的复合终点发生率（2.2%）。未经调整的预后情况显示，随着外科医生年CEA手术量的增加而改善。处于职业生涯中期的外科医生的死亡率和卒中发生率低于职业生涯早期或晚期的外科医生。手术由手术量最低的医疗服务提供者（五分位数1；每年0 - 11例CEA手术）进行时，死亡几率增加（比值比[OR] 2.62，95%置信区间[CI] 1.3 - 5.28），或者由未接受专科培训的（普通）外科医生进行手术时，死亡几率也增加（OR 1.64，95% CI 1.01 - 2.67）。在对所有患者层面的因素进行调整后，医疗服务提供者的手术量仍然是预后的独立预测因素，五分位数1（OR 2.57，95% CI 1.27 - 5.23）和五分位数2（每年12 - 22例CEA手术）（0.30%；OR 2.07，95% CI 1 - 4.27）的外科医生的死亡几率显著增加。
无症状性疾病患者行CEA术后不良事件相对少见。然而，外科医生特征会影响预后，高手术量、处于职业生涯中期且接受过专科培训的外科医生能带来最佳预后结果。确定无症状性颈动脉粥样硬化的最佳治疗方法时，必须考虑外科医生特征对患者预后的影响。
