van Leeuwen Marina T, Falster Michael O, Vajdic Claire M, Crowe Philip J, Lujic Sanja, Klaes Elizabeth, Jorm Louisa, Sedrakyan Art
Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia.
Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia.
BMJ Open. 2018 Apr 10;8(4):e020858. doi: 10.1136/bmjopen-2017-020858.
To investigate between-hospital variation in the probability of reoperation within 90 days of initial breast-conserving surgery (BCS), and the contribution of health system-level and other factors.
Population-based, retrospective cohort study.
New South Wales (NSW), Australia.
Linked administrative hospitalisation data were used to define a cohort of adult women undergoing initial BCS for breast cancer in NSW between 1 July 2002 and 31 December 2013.
Multilevel, cross-classified models with patients clustered within hospitals and residential areas were used to examine factors associated with any reoperation, and either re-excision or mastectomy, within 90 days.
Of 34 458 women undergoing BCS, 29.1% underwent reoperation within 90 days, half of which were mastectomies. Overall, the probability of reoperation decreased slightly over time. However, there were divergent patterns by reoperation type; the probability of re-excision increased alongside a concomitant decrease in the probability of mastectomy. Significant between-hospital variation was observed. Non-metropolitan location and surgery at low-volume hospitals were associated with a higher overall probability of reoperation, and of mastectomy specifically, after accounting for patient-level factors, calendar year and area-level socioeconomic status. The magnitude of association with geographical location and surgical volume decreased over time.
Reoperation rates within 90 days of BCS varied significantly between hospitals. For women undergoing mastectomy after BCS, this represents a dramatic change in clinical course. Multilevel modelling suggests unwarranted clinical variation may be an issue, likely due to disparities in access to multidisciplinary breast cancer care and preoperative diagnostic procedures. However, the observed reduction in disparities over time is encouraging and indicates that guidelines and policy initiatives have the potential to improve regional breast cancer care.
调查初次保乳手术（BCS）后90天内再次手术概率的医院间差异，以及卫生系统层面和其他因素的作用。
基于人群的回顾性队列研究。
澳大利亚新南威尔士州（NSW）。
利用关联的行政住院数据定义了2002年7月1日至2013年12月31日在新南威尔士州因乳腺癌接受初次保乳手术的成年女性队列。
采用患者在医院和居住地区内聚类的多水平交叉分类模型，研究90天内与任何再次手术以及再次切除或乳房切除术相关的因素。
在34458名接受保乳手术的女性中，29.1%在90天内接受了再次手术，其中一半是乳房切除术。总体而言，再次手术的概率随时间略有下降。然而，不同再次手术类型呈现出不同模式；再次切除的概率增加，同时乳房切除术的概率相应下降。观察到显著的医院间差异。在考虑患者层面因素、日历年和地区层面社会经济地位后，非大都市地区以及在手术量低的医院进行手术与总体再次手术概率较高相关，尤其是与乳房切除术概率较高相关。与地理位置和手术量的关联程度随时间下降。
保乳手术后90天内的再次手术率在医院间存在显著差异。对于保乳手术后接受乳房切除术的女性，这代表了临床病程的巨大变化。多水平建模表明不必要的临床差异可能是一个问题，可能是由于获得多学科乳腺癌护理和术前诊断程序存在差异。然而，观察到的差异随时间减少令人鼓舞，表明指南和政策举措有可能改善区域乳腺癌护理。
