Department of Vascular Surgery, Prince of Wales Hospital, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia.
Department of Vascular Surgery, Prince of Wales Hospital, Sydney, Australia; Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, UK.
Eur J Vasc Endovasc Surg. 2019 Apr;57(4):510-519. doi: 10.1016/j.ejvs.2018.09.019. Epub 2018 Oct 24.
Operative caseload is thought to be associated with peri-operative mortality following intact aortic aneurysm repair. The aim was to study that association in the Australian setting, which has a unique healthcare provision system and geographical population distribution.
The Australasian Vascular Audit database was used to capture volume measurements for both individual surgeon and hospital and to separate it into quintiles (1, lowest, to 5, highest) for endovascular (EVAR), open surgical repair (OSR), and subgroups of repair types between 2010 and 2016. Multivariable logistic regression modelling was used to assess the impact of caseload volumes on in hospital mortality after adjustment for confounders.
Volume counts were determined from 14,262 aneurysm repair procedures (4121 OSR, 10,106 EVAR). After exclusions, 2181 OSR (161 complex, 2020 standard) and 7547 EVAR (6198 standard, 1135 complex, 214 thoracic (TEVAR)) elective cases were available for volume analysis. Unadjusted mortality after EVAR was unaffected by either surgeon (Quintile 1, 1.0%; Quintile 5, 0.9%; p = .28) or hospital volume (Quintile 1, 0.8%; Quintile 5, 1.3%; p = .47). However, univariable analysis of the TEVAR subgroup revealed a significant correlation with hospital volume (Quintiles 1-2 vs. Quintiles 3-5; p = .02). Univariable analysis for OSR demonstrated a marginal, non-significant value for surgeon (Quintile 1, 4.0%; Quintile 5, 3.6%; p = .06), but not hospital volume (Quintile 1, 4.7%; Quintile 5, 4.0%; p = .67). After adjustment for confounders hospital volume remained a significant predictor of peri-operative TEVAR mortality (Quintile 1-2 vs. 3-5; OR 5.62, 95% CI 1.27-24.83; p = .02) and surgeon volume a predictor following standard OSR (Quintile 1-2 vs. Quintile 3-5; OR 2.15, 95% CI 1.21-3.83; p = .01).
There is an inverse correlation between both surgeon volume of open aortic aneurysm repair, hospital volume of thoracic endovascular aneurysm repair and in hospital mortality. These findings suggest that in Australia TEVAR should be performed by high volume hospitals and OSR by high volume surgeons.
有研究认为，手术量与完整主动脉瘤修复术后围手术期死亡率有关。本研究旨在研究澳大利亚的这种关联，因为澳大利亚具有独特的医疗服务提供系统和地理人口分布。
使用澳大利亚血管审核数据库来获取每位外科医生和医院的手术量，并将其分为五分位数（1，最低，至 5，最高），用于血管内修复术（EVAR）、开放手术修复（OSR）以及 2010 年至 2016 年间修复类型的亚组。使用多变量逻辑回归模型，在调整混杂因素后，评估手术量对住院死亡率的影响。
从 14262 例动脉瘤修复手术（4121 例 OSR，10106 例 EVAR）中确定了手术量。排除后，有 2181 例 OSR（161 例复杂，2020 例标准）和 7547 例 EVAR（6198 例标准，1135 例复杂，214 例胸主动脉（TEVAR））择期手术可用于体积分析。EVAR 后的未调整死亡率不受外科医生（五分位数 1，1.0%；五分位数 5，0.9%；p=0.28）或医院量（五分位数 1，0.8%；五分位数 5，1.3%；p=0.47）的影响。然而，TEVAR 亚组的单变量分析显示与医院量显著相关（五分位数 1-2 与五分位数 3-5；p=0.02）。OSR 的单变量分析显示，外科医生量有一个边缘但无统计学意义的值（五分位数 1，4.0%；五分位数 5，3.6%；p=0.06），但医院量没有（五分位数 1，4.7%；五分位数 5，4.0%；p=0.67）。在调整混杂因素后，医院量仍然是 TEVAR 围手术期死亡率的显著预测因素（五分位数 1-2 与 3-5；OR 5.62，95%CI 1.27-24.83；p=0.02），外科医生量是标准 OSR 的预测因素（五分位数 1-2 与五分位数 3-5；OR 2.15，95%CI 1.21-3.83；p=0.01）。
开放主动脉瘤修复术的外科医生手术量、胸主动脉血管内修复术的医院量与住院死亡率呈反比关系。这些发现表明，在澳大利亚，TEVAR 应由高手术量医院进行，OSR 应由高手术量外科医生进行。
