From the Department of Radiology, Penn State College of Medicine, Hershey, PA; Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA; and Center for Optimizing Radiology Value, Milton S. Hershey Medical Center, Hershey, PA.
ASAIO J. 2018 Jul/Aug;64(4):450-457. doi: 10.1097/MAT.0000000000000675.
This article seeks to understand whether a volume-outcome relationship exists in adult extracorporeal membrane oxygenation (ECMO). We examined primary administrative discharge data from the Pennsylvanian Health Care Cost Containment Council for all 2,948 consecutive adults treated with ECMO in Pennsylvania between January 1, 2007, and December 31, 2015. We used a well-fitting backwards stepwise logistic regression to obtain patient-level predicted mortality. Number of cases and risk-adjusted mortality was aggregated by calendar quarter and by hospital. Graphical and correlation analysis was used to understand the volume-outcome relationship, focusing separately on the impact of a hospital's current scale (annual volume of adult ECMO) and a hospital's cumulative experience (total cumulative volume of adult ECMO since starting operations). We found that more than 9 years, there was essentially no reduction in overall risk-adjusted mortality in the state. For individual hospitals, once institutions had as few as 50 cases' total experience or performed just 10 cases annually, there was no clear improvement in outcomes. Patients in hospitals with fewer than 50 cases ever performed appeared objectively less sick compared with patients in hospital with more experience. We conclude that there is little evidence of volume-outcome relationships in adult ECMO in this state, although we acknowledge that the absence of clinical chart data limits these conclusions.
本文旨在探讨成人体外膜肺氧合（ECMO）中是否存在量效关系。我们分析了宾夕法尼亚州卫生保健成本控制委员会的主要行政出院数据，该数据涵盖了 2007 年 1 月 1 日至 2015 年 12 月 31 日期间在宾夕法尼亚州接受 ECMO 治疗的 2948 名连续成人患者。我们使用拟合良好的向后逐步逻辑回归来获得患者水平的预测死亡率。按日历季度和医院对病例数和风险调整死亡率进行了汇总。使用图形和相关分析来了解量效关系，分别关注医院当前规模（成人 ECMO 的年度病例数）和医院累计经验（自运营以来成人 ECMO 的总累计病例数）的影响。结果发现，9 年多来，该州的总体风险调整死亡率基本没有下降。对于个别医院，一旦机构的总经验达到 50 例或每年仅进行 10 例，结果就没有明显改善。与经验丰富的医院相比，开展病例数少于 50 例的医院的患者病情似乎明显较轻。我们的结论是，尽管我们承认缺乏临床图表数据限制了这些结论，但该州成人 ECMO 中几乎没有证据表明存在量效关系。
