Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH.
Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH.
Surgery. 2020 Jul;168(1):92-100. doi: 10.1016/j.surg.2020.02.024. Epub 2020 Apr 14.
Assessing composite measures of quality such as textbook outcome may be superior to focusing on individual parameters when evaluating hospital performance. The aim of the current study was to assess the impact of teaching hospital status on the occurrence of a textbook outcome after hepatopancreatic surgery.
The Medicare Inpatient Standard Analytic Files were used to identify patients undergoing hepatopancreatic surgery from 2013 to 2015 for a malignant indication. Stratified and multivariable regression analyses were performed to determine the relationship between teaching hospital status, hospital surgical volume and textbook outcome.
Among 8,035 Medicare patients (hepatectomy; 41.8%, pancreatectomy; 58.2%), 6,196 (77.1%) patients underwent surgery at a major teaching hospital, whereas 1,839 (22.9%) patients underwent surgery at a minor teaching hospital. Patients undergoing surgery for pancreatic cancer at a major teaching hospital had a greater likelihood of achieving a textbook outcome compared with patients treated at a minor teaching hospital (minor teaching hospital: 456, 40% versus major teaching hospital: 1,606, 45.4%; P = .002). The likelihood of textbook outcome was also greater among patients undergoing hepatopancreatic surgery at high-volume centers (pancreas, low volume: 875, 40.5% versus high volume: 1,187, 47.1% P < .001; liver, low volume: 608, 41.8% versus high volume: 886, 46.6%; P = .005). When examining only major teaching hospitals, patients undergoing a pancreatectomy at a high-volume center had 29% greater odds of achieving a textbook outcome (odds ratio 1.29, 95% confidence interval 1.12-1.49). In contrast, among patients undergoing pancreatic resection at high-volume centers, the odds of achieving a textbook outcome was comparable among major versus minor teaching hospital (odds ratio 1.17, 95% confidence interval 0.89-1.53).
The odds of achieving a textbook outcome after pancreatic and hepatic surgery was greater at major versus minor teaching hospitals; however, this effect was largely mediated by hepatopancreatic procedural volume. Patients and payers should focus on regionalization of pancreatic and liver resection to high-volume centers in an effort to optimize the chances of achieving a textbook outcome.
评估综合质量指标，如教科书结果，可能优于在评估医院绩效时仅关注个别参数。本研究的目的是评估教学医院地位对肝胆胰手术后教科书结果发生的影响。
使用医疗保险住院标准分析文件，从 2013 年至 2015 年确定因恶性肿瘤接受肝胆胰手术的患者。采用分层和多变量回归分析，确定教学医院地位、医院手术量与教科书结果之间的关系。
在 8035 名医疗保险患者（肝切除术：41.8%，胰切除术：58.2%）中，6196 名（77.1%）患者在主要教学医院接受手术，而 1839 名（22.9%）患者在次要教学医院接受手术。与在小型教学医院治疗的患者相比，在主要教学医院接受胰腺恶性肿瘤手术的患者更有可能达到教科书结果（小型教学医院：456 例，40%，主要教学医院：1606 例，45.4%；P = 0.002）。在高容量中心接受肝胆胰手术的患者中，达到教科书结果的可能性也更高（胰脏，低容量：875 例，40.5%，高容量：1187 例，47.1%，P < 0.001；肝脏，低容量：608 例，41.8%，高容量：886 例，46.6%，P = 0.005）。当仅检查主要教学医院时，在高容量中心接受胰切除术的患者达到教科书结果的可能性增加 29%（优势比 1.29，95%置信区间 1.12-1.49）。相比之下，在高容量中心接受胰腺切除术的患者中，主要教学医院与小型教学医院达到教科书结果的可能性相当（优势比 1.17，95%置信区间 0.89-1.53）。
与小型教学医院相比，主要教学医院行胰腺和肝手术后达到教科书结果的可能性更高；然而，这种影响在很大程度上是由肝胆胰手术量介导的。患者和支付者应关注将胰腺和肝脏切除术区域化到高容量中心，以优化达到教科书结果的机会。
