From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York (S.G.M., C.C., E.E.M.) Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria (S.G.M., C.C., E.E.M.) Institute for Healthcare Delivery Science, Departments of Population Health Science and Policy (J.P., N.Z., A.O., M.M.) Departments of Orthopedic Surgery (J.P.) Medicine (J.P.) Icahn School of Medicine at Mount Sinai, New York, New York; Department of Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California (E.R.M.) Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California (E.R.M).
Anesthesiology. 2018 Sep;129(3):428-439. doi: 10.1097/ALN.0000000000002299.
Neuraxial anesthesia is increasingly recommended for hip/knee replacements as some studies show improved outcomes on the individual level. With hospital-level studies lacking, we assessed the relationship between hospital-level neuraxial anesthesia utilization and outcomes.
National data on 808,237 total knee and 371,607 hip replacements were included (Premier Healthcare 2006 to 2014; 550 hospitals). Multivariable associations were measured between hospital-level neuraxial anesthesia volume (subgrouped into quartiles) and outcomes (respiratory/cardiac complications, blood transfusion/intensive care unit need, opioid utilization, and length/cost of hospitalization). Odds ratios (or percent change) and 95% CI are reported. Volume-outcome relationships were additionally assessed by plotting hospital-level neuraxial anesthesia volume against predicted hospital-specific outcomes; trend tests were applied with trendlines' R statistics reported.
Annual hospital-specific neuraxial anesthesia volume varied greatly: interquartile range, 3 to 78 for hips and 6 to 163 for knees. Increasing frequency of neuraxial anesthesia was not associated with reliable improvements in any of the study's clinical outcomes. However, significant reductions of up to -14.1% (95% CI, -20.9% to -6.6%) and -15.6% (95% CI, -22.8% to -7.7%) were seen for hospitalization cost in knee and hip replacements, respectively, both in the third quartile of neuraxial volume. This coincided with significant volume effects for hospitalization cost; test for trend P < 0.001 for both procedures, R 0.13 and 0.41 for hip and knee replacements, respectively.
Increased hospital-level use of neuraxial anesthesia is associated with lower hospitalization cost for lower joint replacements. However, additional studies are needed to elucidate all drivers of differences found before considering hospital-level neuraxial anesthesia use as a potential marker of quality.
神经轴麻醉越来越多地被推荐用于髋关节/膝关节置换术，因为一些研究表明在个体水平上会有更好的效果。由于缺乏医院层面的研究，我们评估了医院层面神经轴麻醉使用率与结果之间的关系。
纳入了 808237 例全膝关节置换术和 371607 例髋关节置换术的国家数据（Premier Healthcare 2006 年至 2014 年；550 家医院）。使用多变量关联来衡量医院层面神经轴麻醉量（分为四分之一）与结果（呼吸/心脏并发症、输血/重症监护需要、阿片类药物使用以及住院时间/费用）之间的关系。报告比值比（或百分比变化）和 95%置信区间。通过绘制医院层面神经轴麻醉量与预测的医院特定结果之间的关系来评估体积-结果关系；应用趋势检验，并报告趋势线的 R 统计量。
医院层面神经轴麻醉的年度特定量差异很大：髋关节的四分位间距为 3 至 78，膝关节为 6 至 163。神经轴麻醉的频率增加与任何研究的临床结果的可靠改善均无关联。然而，在膝关节和髋关节置换术中，分别在神经轴体积的第三四分位数中，住院费用显著降低了 14.1%（95%CI，-20.9%至-6.6%）和 15.6%（95%CI，-22.8%至-7.7%）。这与住院费用的显著体积效应相吻合；两种手术的趋势检验 P<0.001，R 值分别为 0.13 和 0.41。
医院层面神经轴麻醉使用率的增加与较低关节置换术的住院费用降低相关。然而，在考虑将医院层面神经轴麻醉使用率作为质量的潜在标志物之前，还需要进一步的研究来阐明发现的差异的所有驱动因素。
