医院手术量、外科医生手术量及外科医生经验与游离组织移植术后并发症和30天再入院率的相关性：一项全国性人群研究。
The Associations of Hospital Volume, Surgeon Volume, and Surgeon Experience with Complications and 30-Day Rehospitalization after Free Tissue Transfer: A National Population Study.
作者信息
Mahmoudi Elham, Lu Yiwen, Chang Shu-Chen, Lin Chia-Yu, Wang Yi-Chun, Chang Chee Jen, Cheng Ming-Huei, Chung Kevin C
机构信息
Ann Arbor, Mich.; and Tao-Yuan, Taiwan.
From the Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School; the Research Services Center for Health Information, the Graduate Institute of Clinical Medicine, and the Clinical Informatics and Medical Statistics Research Center, Chang Gung University; and the Department of Plastic and Reconstructive Surgery and the Resource Center for Clinical Research, Chang Gung Memorial Hospital.
出版信息
Plast Reconstr Surg. 2017 Aug;140(2):403-411. doi: 10.1097/PRS.0000000000003515.
BACKGROUND
Greater provider volume is associated with better outcomes. There is, however, a paucity of evidence on volume-outcome associations for surgical complications and 30-day all-cause rehospitalization after free tissue transfer or free flap surgery. Surgical complications and frequent rehospitalization are important quality indicators that substantially hinder appropriate health care spending. The authors hypothesized that increased provider volume and surgeon experience are associated with lower complication and hospital readmission rates.
METHODS
The authors conducted a retrospective cohort study of adults aged 18 to 64 years who underwent free tissue transfer. They examined 100 percent of all free tissue transfers between 2001 and 2012 using Taiwan's national data, and used regression modeling to examine associations between volume and outcome. All models were adjusted for patient, surgeon, and hospital characteristics.
RESULTS
Seventeen percent of free tissue transfer operations (4201 of 25,327) had complications. Infection was the most prevalent after free tissue transfer (70 percent), and the 30-day rehospitalization rate was approximately 20 percent. Hospital volume was associated with a small decrease in complications (OR, 0.99; 95 percent CI, 0.99 to 0.99; p < 0.01). For surgeons, years of experience and not annual case volume decreased surgical complications (OR, 0.98; 95 percent CI, 0.97 to 0.99; p = 0.01). The authors did not find any association between hospital or surgeon volume, or surgeon's years of experience and 30-day rehospitalization.
CONCLUSIONS
Higher-volume hospitals and more experienced surgeons were shown to have a lower likelihood of postsurgery complications. Hospital process and structure affect outcomes and reduce surgical complications. Reducing 30-day rehospitalization may require payment reform, as it demands coordinated care before and after hospital discharge.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
背景
医疗服务提供者的手术量越大，治疗效果越好。然而，关于游离组织移植或游离皮瓣手术后手术并发症与30天全因再住院率之间的手术量-结局关联，证据却很少。手术并发症和频繁再住院是重要的质量指标，严重阻碍了合理的医疗保健支出。作者推测，医疗服务提供者手术量的增加和外科医生经验的丰富与较低的并发症和再住院率相关。
方法
作者对18至64岁接受游离组织移植的成年人进行了一项回顾性队列研究。他们利用台湾的全国数据，对2001年至2012年间的所有游离组织移植进行了100%的检查，并使用回归模型来研究手术量与结局之间的关联。所有模型均根据患者、外科医生和医院的特征进行了调整。
结果
17%的游离组织移植手术（25327例中的4201例）出现并发症。感染是游离组织移植后最常见的并发症（70%），30天再住院率约为20%。医院手术量与并发症的小幅减少相关（比值比，0.99；95%置信区间，0.99至0.99；p<0.01）。对于外科医生来说，手术经验年限而非年度手术量降低了手术并发症（比值比，0.98；95%置信区间，0.97至0.99；p=0.01）。作者未发现医院或外科医生手术量、外科医生经验年限与30天再住院之间存在任何关联。
结论
手术量较大的医院和经验更丰富的外科医生术后并发症发生的可能性较低。医院的流程和结构会影响治疗效果并减少手术并发症。减少30天再住院可能需要支付改革，因为这需要在出院前后进行协调护理。
临床问题/证据级别：治疗性，III级
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