Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, OH.
Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, OH.
Surgery. 2019 Dec;166(6):1135-1141. doi: 10.1016/j.surg.2019.06.020. Epub 2019 Jul 31.
Patients undergoing complex surgery at safety net hospitals have been shown to suffer inferior short-term outcomes. Liver transplantation, one of the most complex surgical interventions, is offered at certain safety net hospitals. We sought to identify whether patients undergoing liver transplantation at safety net hospitals have inferior outcomes compared with lower burden centers.
Using a link between the University HealthSystem Consortium and Scientific Registry of Transplant Recipient databases, we identified 11,047 patients undergoing liver transplantation at 63 centers between 2009 and 2012. Hospitals were grouped by safety net burden, defined as the proportion of Medicaid or uninsured patient encounters during that time. The highest quartile (safety net hospitals) was compared to medium- and low-burden hospitals regarding recipient and donor characteristics, perioperative outcomes, and long-term survival.
Liver transplantation recipients at safety net hospitals were more often black and of lower socioeconomic status (P < .01), but had similar model for end-stage liver disease scores (20 vs 20 vs 18) compared with median-burden hospitals and low burden hospitals. Length of stay and readmission rates were similar; however, safety net hospitals demonstrated higher in-hospital mortality (5.2% vs 4.5% vs 2.9%, P < .01). Despite this, there was no significant difference in overall patient or graft survivals in patients who underwent liver transplantation at safety net hospitals and survived the perioperative setting at a median follow-up of 2 years (P > .05).
Despite differences in perioperative outcomes at safety net hospitals, these centers achieve noninferior long-term patient and graft survival for potentially vulnerable patients requiring liver transplantation. Strict care standardization, as achieved in liver transplantation, may be a mechanism by which outcomes can be improved at safety net hospitals after other complex surgical procedures.
在保障医疗服务体系医院接受复杂手术的患者，其短期预后较差。肝脏移植是最复杂的手术干预之一，某些保障医疗服务体系医院提供这种治疗。我们旨在确定在保障医疗服务体系医院接受肝脏移植的患者是否比低负担中心的患者预后更差。
通过大学卫生系统联盟与移植受者登记处数据库之间的联系，我们确定了 2009 年至 2012 年间在 63 个中心接受肝脏移植的 11047 例患者。根据在此期间 Medicaid 或无保险患者就诊比例，将医院分为保障医疗服务体系负担的高低。将最高四分位数（保障医疗服务体系医院）与中低负担医院进行比较，比较内容包括受者和供者特征、围手术期结果和长期生存情况。
保障医疗服务体系医院的肝脏移植受者更可能为黑人且社会经济地位较低（P <.01），但与中负担医院和低负担医院相比，模型终末期肝病评分相似（20 分比 20 分比 18 分）。住院时间和再入院率相似；然而，保障医疗服务体系医院的院内死亡率更高（5.2%比 4.5%比 2.9%，P <.01）。尽管如此，在保障医疗服务体系医院接受肝脏移植并在围手术期存活下来的患者中，在中位随访 2 年后，患者和移植物的总体生存率没有显著差异（P >.05）。
尽管保障医疗服务体系医院的围手术期结果存在差异，但这些中心为需要肝脏移植的高危患者实现了非劣效的长期患者和移植物生存率。严格的护理标准化，如肝脏移植中实现的那样，可能是在其他复杂手术后改善保障医疗服务体系医院的结果的一种机制。
