Jean Raymond A, O'Neill Kathleen M, Pei Kevin Y, Davis Kimberly A
National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
J Surg Res. 2017 Jun 15;214:23-31. doi: 10.1016/j.jss.2017.02.045. Epub 2017 Mar 3.
Volume-to-outcome data have been studied in several complex surgical procedures, demonstrating improved outcomes at higher volume centers. Laparoscopic lysis of adhesions (LLOA) for small bowel obstruction (SBO) may result in better outcomes, but there is no information on the learning curve for this potentially complex case. This study evaluates the effect of institutional procedural volume on length of stay (LOS), outcomes, and costs in LLOA for SBOs.
The Nationwide Inpatient Sample data set between 2000 and 2013 was queried for discharges for a diagnosis of SBO involving LLOA in adult patients. Patients with intra-abdominal malignancy and evidence of any other major surgical procedure during hospitalization were excluded. The procedural volume per hospital was calculated over the period, and high-volume hospitals were designated as those performing greater than five LLOA per year. Patient characteristics were described by hospital volume status using stratified cluster sampling tabulation and linear regression methods. LOS, total charges, and costs were reported as means with standard deviation and median values. P < 0.05 was considered significant.
A total of 9111 discharges were selected, which was representative of 43,567 weighted discharges nationally between 2000 and 2013. Over the study period, there has been a 450% increase in the number of LLOA performed. High-volume hospitals had significantly shorter LOS (mean: 4.92 ± standard error (SE) 0.13 d; median: 3.6) compared to low-volume hospitals (mean: 5.68 ± 0.06 d; median: 4.5). In multivariate analysis, high-volume status was associated with a decreased LOS of 0.72 d (P < 0.0001) as compared to low-volume status. Other significant predictors for decreased LOS included decreased age, decreased comorbidity, and the absence of small bowel resection. There was no significant association between volume status and total charges in multivariate or univariate models, but high-volume hospitals were associated with lower costs in multivariate models by approximately $984 (P = 0.017).
This study demonstrates that high hospital volume was associated with decreased LOS for LLOA in SBO. Although volume was not associated with differences in total charges, there was a small decrease in hospital costs.
在几种复杂的外科手术中已对手术量与治疗结果的数据进行了研究，结果表明在手术量较大的中心治疗效果更佳。腹腔镜粘连松解术（LLOA）治疗小肠梗阻（SBO）可能会带来更好的治疗效果，但对于这种潜在复杂病例的学习曲线尚无相关信息。本研究评估了机构手术量对SBO的LLOA治疗中住院时间（LOS）、治疗结果和成本的影响。
查询2000年至2013年全国住院患者样本数据集，以获取诊断为SBO且接受LLOA治疗的成年患者出院信息。排除有腹腔内恶性肿瘤以及住院期间有任何其他 major 外科手术证据的患者。计算该时间段内每家医院的手术量，手术量大的医院定义为每年进行超过5例LLOA手术的医院。使用分层整群抽样列表法和线性回归方法按医院手术量状态描述患者特征。LOS、总费用和成本以均值（标准差）和中位数报告。P < 0.05被认为具有统计学意义。
共选取9111例出院病例，代表了2000年至2013年全国43567例加权出院病例。在研究期间，LLOA手术量增加了450%。与手术量小的医院相比，手术量大的医院LOS显著缩短（均值：4.92 ± 标准误（SE）0.13天；中位数：3.6天），而手术量小的医院LOS均值为5.68 ± 0.06天，中位数为4.5天。在多变量分析中，与手术量小的医院相比，手术量大的医院LOS减少0.72天（P < 0.0001）。LOS缩短的其他显著预测因素包括年龄降低、合并症减少以及未进行小肠切除术。在多变量或单变量模型中，手术量状态与总费用之间无显著关联，但在多变量模型中，手术量大的医院成本降低约984美元（P = 0.017）。
本研究表明，医院手术量高与SBO的LLOA治疗中LOS缩短相关。虽然手术量与总费用差异无关，但医院成本略有降低。
