Center for Surgery and Public Health, Brigham & Women's Hospital, Boston, MA.
Department of Surgery, Howard University, Washington, DC.
Surgery. 2018 Nov;164(5):1109-1116. doi: 10.1016/j.surg.2018.07.008. Epub 2018 Aug 31.
Hospital-level variation has been found to influence outcomes in emergency general surgery. However, whether the individual surgeon plays a role in this variation is unknown.
We performed an analysis of the Florida State Inpatient Database (2010-2014), which is linked to the American Hospital Association's Annual Survey Database, including patients who emergently underwent 1 or more of 7 procedures (laparotomy, adhesiolysis, small bowel resection, colectomy, repair of a perforated gastric ulcer, appendectomy, or cholecystectomy). We used multilevel random effects modeling to quantify the amount of variation in mortality, complications, and 30-day readmissions attributable to surgeons. Patient clinical and demographic factors, as well as hospital-level factors, were introduced into the model in a forward stepwise fashion, and the percent of the variation attributable to surgeons was derived.
Our study included 2,149 surgeons across 224 hospitals, with a total of 569,767 emergency general surgery cases. The overall unadjusted mortality rate was 3.8%, and the complication and readmission rates were 12.7% and 27.7%, respectively. Surgeon-level variation had the greatest impact on mortality, explaining 32.77% of the overall variability in mortality risk compared with 0.08% and 2.28% for complications and readmissions, respectively. Peptic ulcer disease operations were most susceptible to surgeon-level variation in mortality and readmissions, whereas appendectomies and cholecystectomies were least susceptible to surgeon-level variation for all outcomes.
Surgeon-level variation contributes to a significant portion of mortality in EGS. This variation is most pronounced in surgery for peptic ulcer disease, a high-risk, low-frequency surgical condition. Programs to reduce mortality in emergency general surgery should address reducing variability in practice with attention to high-risk, low-frequency procedures.
医院层面的差异已被发现会影响急诊普通外科的结局。然而，个体外科医生是否在这种差异中发挥作用尚不清楚。
我们对佛罗里达州住院患者数据库（2010-2014 年）进行了分析，该数据库与美国医院协会年度调查数据库相关联，包括紧急接受 1 种或多种 7 种手术的患者（剖腹术、粘连松解术、小肠切除术、结肠切除术、胃穿孔溃疡修复术、阑尾切除术或胆囊切除术）。我们使用多水平随机效应模型来量化死亡率、并发症和 30 天再入院率归因于外科医生的差异量。患者的临床和人口统计学因素以及医院层面的因素以逐步向前的方式引入模型，并得出归因于外科医生的变异百分比。
我们的研究包括 224 家医院的 2149 名外科医生，共进行了 569767 例急诊普通外科手术。总的未调整死亡率为 3.8%，并发症发生率和再入院率分别为 12.7%和 27.7%。外科医生层面的差异对死亡率的影响最大，与并发症（2.28%）和再入院率（0.08%）相比，解释了死亡率风险总体变异性的 32.77%。与所有结局相比，胃溃疡疾病手术的死亡率和再入院率最容易受到外科医生层面差异的影响，而阑尾切除术和胆囊切除术则最不容易受到外科医生层面差异的影响。
外科医生层面的差异导致 EGS 中死亡率的显著部分。这种差异在胃溃疡疾病手术中最为明显，这是一种高风险、低频率的手术情况。旨在降低急诊普通外科死亡率的项目应通过关注高风险、低频率的手术来减少实践中的变异性。
