Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX.
Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH.
Spine (Phila Pa 1976). 2019 May 1;44(9):659-669. doi: 10.1097/BRS.0000000000002910.
Retrospective cohort study.
The objective of the present study was to establish evidence-based volume thresholds for surgeons and hospitals predictive of enhanced value in the setting of laminectomy.
Previous studies have attempted to characterize the relationship between volume and value; however, none to the authors' knowledge has employed an evidence-based approach to identify thresholds yielding enhanced value.
In total, 67,758 patients from the New York Statewide Planning and Research Cooperative System database undergoing laminectomy in the period 2009 to 2015 were included. We used stratum-specific likelihood ratio analysis of receiver operating characteristic curves to establish volume thresholds predictive of increased length of stay (LOS) and cost for surgeons and hospitals.
Analysis of LOS by surgeon volume produced strata at: <17 (low), 17 to 40 (medium), 41 to 71 (high), and >71 (very high). Analysis of cost by surgeon volume produced strata at: <17 (low), 17 to 33 (medium), 34 to 86 (high), and >86 (very high). Analysis of LOS by hospital volume produced strata at: <43 (very low), 43 to 96 (low), 97 to 147 (medium), 148 to 172 (high), and >172 (very high). Analysis of cost by hospital volume produced strata at: <43 (very low), 43 to 82 (low), 83 to 115 (medium), 116 to 169 (high), and >169 (very high). LOS and cost decreased significantly (P < 0.05) in progressively higher volume categories for both surgeons and hospitals. For LOS, medium-volume surgeons handle the largest proportion of laminectomies (36%), whereas very high-volume hospitals handle the largest proportion (48%).
This study supports a direct volume-value relationship for surgeons and hospitals in the setting of laminectomy. These findings provide target-estimated thresholds for which hospitals and surgeons may receive meaningful return on investment in our increasingly value-based system. Further value-based optimization is possible in the finding that while the highest volume hospitals handle the largest proportion of laminectomies, the highest volume surgeons do not.
回顾性队列研究。
本研究的目的是建立基于证据的手术医生和医院手术量阈值，以预测椎板切除术的附加值。
先前的研究试图描述手术量与价值之间的关系；然而，据作者所知，没有一项研究采用基于证据的方法来确定产生附加值的阈值。
共纳入了来自纽约州规划与研究合作系统数据库中 2009 年至 2015 年间接受椎板切除术的 67758 例患者。我们使用分层特异性似然比分析受试者工作特征曲线，以确定手术医生和医院手术量预测住院时间（LOS）和费用增加的阈值。
手术医生 LOS 分析产生了以下亚组：<17（低）、17-40（中）、41-71（高）和>71（极高）。手术医生费用分析产生了以下亚组：<17（低）、17-33（中）、34-86（高）和>86（极高）。医院 LOS 分析产生了以下亚组：<43（极低）、43-96（低）、97-147（中）、148-172（高）和>172（极高）。医院费用分析产生了以下亚组：<43（极低）、43-82（低）、83-115（中）、116-169（高）和>169（极高）。手术医生和医院的手术量越高，LOS 和费用显著降低（P<0.05）。对于 LOS，中等手术量的医生处理的椎板切除术比例最大（36%），而高手术量的医院处理的比例最大（48%）。
本研究支持椎板切除术背景下手术医生和医院的直接手术量-价值关系。这些发现为医院和医生提供了有意义的投资回报目标估计阈值，在我们日益重视价值的体系中，这可能会进一步优化基于价值的治疗。进一步的基于价值的优化是可能的，因为尽管最高手术量的医院处理了最大比例的椎板切除术，但最高手术量的医生并没有处理。
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