超高术者或医院手术量是否能改善股骨颈骨折后半髋关节置换术的结局？
Does Very High Surgeon or Hospital Volume Improve Outcomes for Hemiarthroplasty Following Femoral Neck Fractures?
机构信息
Department of Orthopaedic Surgery, Children's Hospital of New Orleans, New Orleans, Louisiana; Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.
Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
出版信息
J Arthroplasty. 2020 May;35(5):1268-1274. doi: 10.1016/j.arth.2019.11.044. Epub 2019 Dec 6.
BACKGROUND
This study evaluates whether very high-volume hip arthroplasty providers have lower complication rates than other relatively high-volume providers.
METHODS
Hemiarthroplasty patients ≥60 years old were identified in the New York Statewide Planning and Research Cooperative System 2001-2015 dataset. Low-volume hospitals (<50 hip arthroplasty cases/y) and surgeons (<10 cases/y) were excluded. The upper and lower quintiles were compared for the remaining "high-volume" hospitals (50-70 vs >245) and surgeons (10-15 vs ≥60) using multivariable Cox proportional hazards regression. Multiple sensitivity analyses were performed treating volume as a continuous variable.
RESULTS
In total, 48,809 patients were included. Very high-volume hospitals demonstrated slightly less pneumonia (6% vs 7%, hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.68-0.88, P < .0001). Very high-volume surgeons experienced slightly higher rates of inpatient morality (3% vs 2%, HR 1.30, 95% CI 1.06-1.60, P = .01), revision surgery (3% vs 3%, HR 1.24, 95% CI 1.02-1.52, P = .03), and implant failure (1% vs <1%, HR 1.80, 95% CI 1.10-2.96, P = .02). Sensitivity analyses did not significantly alter these findings but suggested that inpatient mortality may decline as surgeon volume approaches 30 cases/y before gradually increasing at higher volumes.
CONCLUSION
A clinically meaningful volume-outcome relationship was not identified among very high-volume hemiarthroplasty surgeons or hospitals. Although prior evidence indicates that outcomes can be improved by avoiding very low-volume providers, these results suggest that complications would not be further reduced by directing all hemiarthroplasty patients to very high-volume surgeons or facilities. Future research investigating whether inpatient mortality changes with surgeon volume (particularly around 30 cases/y) in a different dataset would be valuable.
LEVEL OF EVIDENCE
Prognostic Level III.
背景
本研究评估超高容量髋关节置换术提供者与其他相对高容量提供者相比，其并发症发生率是否更低。
方法
在纽约州规划与研究合作系统 2001-2015 年的数据集内，确定了 60 岁以上的半髋关节置换术患者。排除低容量医院（每年<50 例髋关节置换术）和低容量外科医生（每年<10 例）。使用多变量 Cox 比例风险回归比较剩余的“高容量”医院（50-70 例与>245 例）和外科医生（10-15 例与≥60 例）的上下五分位数。还进行了多种敏感性分析，将容量视为连续变量。
结果
共有 48809 例患者入组。超高容量医院的肺炎发生率略低（6%与 7%，风险比[HR]0.77，95%置信区间[CI]0.68-0.88，P<0.0001）。超高容量外科医生的住院死亡率较高（3%与 2%，HR 1.30，95%CI1.06-1.60，P=0.01）、翻修手术发生率较高（3%与 3%，HR 1.24，95%CI1.02-1.52，P=0.03）和假体失败发生率较高（1%与<1%，HR 1.80，95%CI1.10-2.96，P=0.02）。敏感性分析并未显著改变这些发现，但表明住院死亡率可能会随着外科医生的手术量接近 30 例/年而逐渐下降，然后在更高的手术量时逐渐增加。
结论
在超高容量半髋关节置换术外科医生或医院中，并未发现具有临床意义的容量-结果关系。尽管先前的证据表明，可以通过避免极低容量提供者来改善结果，但这些结果表明，将所有半髋关节置换术患者转至超高容量外科医生或机构并不会进一步降低并发症。在不同的数据集内，未来研究调查外科医生的手术量（特别是在 30 例/年左右）是否会改变住院死亡率将具有重要意义。
证据水平
预后 III 级。
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