Meng Rosie, Bright Tim, Woodman Richard J, Watson David I
Flinders University Discipline of Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia.
Flinders Centre for Innovation in Cancer, Flinders Medical Centre, Adelaide, South Australia, Australia.
ANZ J Surg. 2019 Jun;89(6):683-688. doi: 10.1111/ans.15058. Epub 2019 Mar 11.
Volume-outcome relationships for mortality following oesophagectomy have been demonstrated in Europe and the USA, but not in Australia or New Zealand. We determined whether higher volume hospitals achieve better outcomes following oesophagectomy in Australia and New Zealand.
Administrative data for hospitals contributing data to the Health Roundtable were analysed. Hospitals performing oesophagectomy for cancer from July 2008 to June 2015 were grouped according to mean annual caseload: low (1-5), medium (6-11) and high (12+) volume. Univariate and multivariable analyses determined the impact of volume on 30-day and in-hospital mortalities, length of hospital stay and mechanical ventilation following surgery.
A total of 2252 patients underwent oesophagectomy in 65 hospitals. Sixty-eight percent (n = 44) were low-, 26% (n = 17) were medium- and 6% (n = 4) were high-volume hospitals. Seven hundred and sixty-two (34%) procedures were performed in low-, 1042 (46%) in medium- and 448 (20%) in high-volume hospitals. Overall in-hospital mortality was 3.1% and 30-day mortality was 2.1%. In-hospital mortality was lowest in high-volume hospitals; 1.6% versus 2.6% and 4.1% for low- and medium-volume hospitals (P = 0.02). Surgery in high-volume hospitals was shorter (32 min, P = 0.001), and patients were less likely to require post-operative ventilation (16.7% versus 25.3% and 28.0%, P < 0.001), although patients requiring ventilation in high-volume hospitals were ventilated for longer.
A volume-outcome relationship was demonstrated, with overall better performance in higher volume hospitals. Colocation of oesophagectomies to hospitals that can demonstrate appropriate caseload should be considered.
在欧洲和美国已证实食管癌切除术后的死亡率与手术量存在关联，但在澳大利亚和新西兰尚未得到证实。我们确定了在澳大利亚和新西兰，手术量较高的医院食管癌切除术后是否能取得更好的疗效。
分析了向健康圆桌会议提供数据的医院的管理数据。2008年7月至2015年6月期间因癌症行食管癌切除术的医院，根据年均病例数分组：低手术量组（1 - 5例）、中等手术量组（6 - 11例）和高手术量组（12例及以上）。单因素和多因素分析确定手术量对30天死亡率、住院死亡率、住院时间以及术后机械通气的影响。
65家医院共有2252例患者接受了食管癌切除术。68%（n = 44）为低手术量医院，26%（n = 17）为中等手术量医院，6%（n = 4）为高手术量医院。低手术量医院进行了762例（34%）手术，中等手术量医院进行了1042例（46%）手术，高手术量医院进行了448例（20%）手术。总体住院死亡率为3.1%，30天死亡率为2.1%。高手术量医院的住院死亡率最低；低手术量和中等手术量医院分别为4.1%和2.6%，而高手术量医院为1.6%（P = 0.02）。高手术量医院的手术时间较短（32分钟，P = 0.001），患者术后需要通气的可能性较小（分别为16.7%、25.3%和28.0%，P < 0.001），尽管高手术量医院中需要通气的患者通气时间更长。
证实了手术量与疗效之间的关系，手术量较高的医院总体表现更好。应考虑将食管癌切除术安排在能够证明有适当病例数的医院进行。
