Navarro Sergio M, Ramkumar Prem N, Egger Anthony C, Goodwin Ryan C
Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA.
Spine Deform. 2018 Mar-Apr;6(2):156-163. doi: 10.1016/j.jspd.2017.08.001.
Increased surgeon and hospital volume has been associated with improved patient outcomes and cost effectiveness for adolescent idiopathic scoliosis (AIS). However, no evidence-based thresholds that clarify the volume at which these strata occur exist. The objective of this study was to establish statistically meaningful thresholds that define high-volume surgeons and hospitals performing spinal fusion for AIS from those that are low volume with respect to length of stay (LOS) and cost.
Using 3,224 patients undergoing spinal fusion for AIS from an administrative database, we created and applied four models using stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve. We generated four sets of thresholds predictive of adverse outcomes, namely, increased cost and LOS, for both surgeon and hospital volume.
For both LOS and cost, surgeon volume produced the same strata with low volume identified as 0-5 annual surgeries and high as greater than 5. LOS and cost decreased significantly (p < .05) between volume strata. For hospital volume in terms of LOS, low volume was identified as 0-10 annual surgeries and high as greater than 10; in terms of cost, low volume was identified as 0-15 annual surgeries and high as greater than 15. LOS decreased significantly (p < .05) and cost was $1,500 less but not statistically significant between volume strata for hospital volume.
Our study of risk-based volume stratification established a direct volume-value relationship for surgeons and hospitals performing fusion for AIS. A meaningful threshold for low- and high-volume surgeons was established at 5 annual surgeries, but no consensus or clinically meaningful conclusion was reached for hospitals, although the threshold approached 10-15 annual surgeries. This analysis should aid patients, surgeons, and administration reach value-based decisions in the optimal delivery of pediatric spinal fusion for AIS.
外科医生手术量及医院手术量的增加与青少年特发性脊柱侧凸（AIS）患者更好的治疗效果和成本效益相关。然而，目前尚无基于证据的阈值来明确出现这些差异的手术量。本研究的目的是确定具有统计学意义的阈值，以区分进行AIS脊柱融合手术的高手术量外科医生和医院与低手术量的医生和医院，具体依据住院时间（LOS）和成本。
利用行政数据库中3224例接受AIS脊柱融合手术的患者，我们创建并应用了四种模型，通过对受试者工作特征（ROC）曲线进行分层特定似然比（SSLR）分析。我们生成了四组预测不良结局的阈值，即外科医生和医院手术量增加时成本和住院时间的增加。
对于住院时间和成本，外科医生手术量产生的分层相同，低手术量定义为每年0 - 5例手术，高手术量定义为每年大于5例。不同手术量分层之间的住院时间和成本显著降低（p < 0.05）。就住院时间而言，医院手术量的低手术量定义为每年0 - 10例手术，高手术量定义为每年大于10例；就成本而言，低手术量定义为每年0 - 15例手术，高手术量定义为每年大于15例。不同手术量分层之间住院时间显著降低（p < 0.05），成本减少1,500美元，但差异无统计学意义。
我们基于风险的手术量分层研究为进行AIS融合手术的外科医生和医院建立了直接的手术量 - 价值关系。低手术量和高手术量外科医生的一个有意义的阈值设定为每年5例手术，但对于医院而言，尽管阈值接近每年10 - 15例手术，但未达成共识或得出具有临床意义的结论。该分析应有助于患者、外科医生和管理层在为AIS进行最佳小儿脊柱融合手术时做出基于价值的决策。
