Papachristofi Olympia, Klein Andrew A, Mackay John, Nashef Samer, Fletcher Nick, Sharples Linda D
Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK.
Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK.
BMJ Open. 2017 Sep 11;7(9):e016947. doi: 10.1136/bmjopen-2017-016947.
To determine the relative contributions of patient risk profile, local and individual clinical practice on length of hospital stay after cardiac surgery.
Ten-year audit of prospectively collected consecutive cardiac surgical cases. Case-mix adjusted outcomes were analysed in models that included random effects for centre, surgeon and anaesthetist.
UK centres providing adult cardiac surgery.
10 of 36 UK specialist centres agreed to provide outcomes for all major cardiac operations over 10 years. After exclusions (duplicates, cases operated by more than one consultant, deaths and procedures for which the EuroSCORE risk score for cardiac surgery is not appropriate), there were 107 038 cardiac surgical procedures between April 2002 and March 2012, conducted by 127 consultant surgeons and 190 consultant anaesthetists.
Length of stay (LOS) up to 3 months postoperatively.
The principal component of variation in outcomes was patient risk (represented by the EuroSCORE and remaining patient heterogeneity), accounting for 95.43% of the variation for postoperative LOS. The impact of the surgeon and centre was moderate (intra-class correlation coefficients ICC=2.79% and 1.59%, respectively), whereas the impact of the anaesthetist was negligible (ICC=0.19%). Similarly, 96.05% of the variation for prolonged LOS (>11 days) was attributable to the patient, with surgeon and centre less but still influential components (ICC=2.12% and 1.66%, respectively, 0.17% only for anaesthetists). Adjustment for year of operation resulted in minor reductions in variation attributable to surgeons (ICC=2.52% for LOS and 2.23% for prolonged LOS).
Patient risk profile is the primary determinant of variation in LOS, and as a result, current initiatives to reduce hospital stay by modifying consultant performance are unlikely to have a substantial impact. Therefore, substantially reducing hospital stay requires shifting away from a one-size-fits-all approach to cardiac surgery, and seeking alternative treatment options personalised to high-risk patients.
确定患者风险状况、当地及个体临床实践对心脏手术后住院时间的相对影响。
对前瞻性收集的连续心脏手术病例进行为期十年的审计。在包含中心、外科医生和麻醉师随机效应的模型中分析病例组合调整后的结果。
英国提供成人心脏手术的中心。
英国36个专科中心中的10个同意提供10年间所有主要心脏手术的结果。排除重复病例、由多名顾问医生实施手术的病例、死亡病例以及心脏手术欧洲心脏手术风险评估系统（EuroSCORE）风险评分不适用的手术病例后，2002年4月至2012年3月期间共有127名顾问外科医生和190名顾问麻醉师实施了107038例心脏手术。
术后长达3个月的住院时间（LOS）。
结果变异的主要成分是患者风险（由EuroSCORE及其他患者异质性表示），占术后LOS变异的95.43%。外科医生和中心的影响中等（组内相关系数ICC分别为2.79%和1.59%），而麻醉师的影响可忽略不计（ICC = 0.19%）。同样，延长住院时间（>11天）变异的96.05%归因于患者，外科医生和中心的影响较小但仍有影响（ICC分别为2.12%和1.66%，麻醉师仅为0.17%）。对手术年份进行调整后，外科医生导致的变异略有减少（LOS的ICC为2.52%，延长住院时间的ICC为2.23%）。
患者风险状况是住院时间变异的主要决定因素，因此，目前通过改变顾问医生表现来缩短住院时间的举措不太可能产生实质性影响。因此，大幅缩短住院时间需要摒弃心脏手术一刀切的方法，并寻求针对高危患者的个性化替代治疗方案。
