Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland.
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland.
JAMA Otolaryngol Head Neck Surg. 2019 Jan 1;145(1):62-70. doi: 10.1001/jamaoto.2018.2986.
A volume-outcome association exists for larynx cancer surgery, but to date it has not been investigated for specific surgical procedures.
To characterize the volume-outcome association specifically for laryngectomy surgery and to identify a minimum hospital volume threshold associated with improved outcomes.
DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional study, the Nationwide Inpatient Sample was used to identify 45 156 patients who underwent laryngectomy procedures for a malignant laryngeal or hypopharyngeal neoplasm between January 2001 and December 2011. The analysis was performed in 2018. Hospital laryngectomy volume was modeled as a categorical variable.
Associations between hospital volume and in-hospital mortality, complications, length of hospitalization, and costs were examined using multivariate logistic regression analysis.
Among 45 156 patients (mean age, 62.6 years; age range, 20-96 years; 80.2% male) at 5516 hospitals, higher-volume hospitals were more likely to be teaching hospitals in urban locations; were more likely to treat patients who had hypopharyngeal cancer, were of white race/ethnicity, were admitted electively, had no comorbidity, and had private insurance; and were more likely to perform flap reconstruction or concurrent neck dissection. After controlling for all other variables, hospitals treating more than 6 cases per year were associated with lower odds of surgical and medical complications, with a greater reduction in the odds of complications with increasing hospital volume. High-volume hospitals in the top-volume quintile (>28 cases per year) were associated with decreased odds of in-hospital mortality (odds ratio, 0.45; 95% CI, 0.23-0.88), postoperative surgical complications (odds ratio, 0.63; 95% CI, 0.50-0.79), and acute medical complications (odds ratio, 0.63; 95% CI, 0.48-0.81). A statistically meaningful negative association was observed between very high-volume hospital care and the mean incremental length of hospitalization (-3.7 days; 95% CI, -4.9 to -2.4 days) and hospital-related costs (-$4777; 95% CI, -$9463 to -$900).
Laryngectomy outcomes appear to be associated with hospital volume, with reduced morbidity associated with a minimum hospital volume threshold and with reduced mortality, morbidity, length of hospitalization, and costs associated with higher hospital volume. These data support the concept of centralization of complex care at centers able to meet minimum volume thresholds to improve patient outcomes.
喉癌手术存在量效关系，但迄今为止，尚未针对具体手术程序进行研究。
具体描述喉切除术的量效关系，并确定与改善结果相关的最低医院量阈值。
设计、设置和参与者：在这项横断面研究中，使用国家住院患者样本确定了 45156 名在 2001 年 1 月至 2011 年 12 月期间因喉或下咽恶性肿瘤接受喉切除术的患者。分析于 2018 年进行。医院喉切除术量被建模为一个分类变量。
使用多变量逻辑回归分析检查医院量与院内死亡率、并发症、住院时间和成本之间的关联。
在 5516 家医院的 45156 名患者（平均年龄 62.6 岁；年龄范围 20-96 岁；80.2%为男性）中，高容量医院更有可能是位于城市的教学医院；更有可能治疗下咽癌患者、白人、择期入院、无合并症且有私人保险；更有可能进行皮瓣重建或同期颈部清扫术。在控制所有其他变量后，每年治疗超过 6 例的医院与手术和医疗并发症的几率降低相关，随着医院量的增加，并发症的几率降低幅度更大。高容量医院中排名前五分之一（>28 例/年）的医院与院内死亡率（比值比，0.45；95%CI，0.23-0.88）、术后手术并发症（比值比，0.63；95%CI，0.50-0.79）和急性医疗并发症（比值比，0.63；95%CI，0.48-0.81）的几率降低相关。与非常高容量医院护理相关的观察到有统计学意义的负相关，与平均住院时间（-3.7 天；95%CI，-4.9 至-2.4 天）和医院相关费用（-4777 美元；95%CI，-9463 美元至-900 美元）呈负相关。
喉切除术的结果似乎与医院量有关，与最低医院量阈值相关的发病率降低，与更高的医院量相关的死亡率、发病率、住院时间和成本降低。这些数据支持将复杂护理集中在能够达到最低量阈值的中心以改善患者结果的概念。
