Nuffield Department of Population Health, Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK; Nuffield Department of Population Health, Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK.
Nuffield Department of Population Health, Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK; Nuffield Department of Population Health, Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK.
Ann Vasc Surg. 2021 Apr;72:589-600. doi: 10.1016/j.avsg.2020.09.066. Epub 2020 Nov 21.
"Structural factors" relating to organization of hospitals may affect procedural outcomes. This study's aim was to clarify associations between structural factors and outcomes after carotid endarterectomy (CEA) and carotid endarterectomy stenting (CAS).
A systematic review of studies published in English since 2005 was conducted. Structural factors assessed were as follows: population size served by the vascular department; number of hospital beds; availability of dedicated vascular beds; established clinical pathways; surgical intensive care unit (SICU) size; and specialty of surgeon/interventionalist. Primary outcomes were as follows: mortality; stroke; cardiac complications; length of hospital stay (LOS); and cost.
There were 11 studies (n = 95,100 patients) included in this systematic review. For CEA, reduced mortality (P < 0.0001) and stroke rates (P = 0.001) were associated with vascular departments serving >75,000 people. Larger hospitals were associated with lower mortality, stroke rate, and cardiac events, compared with smaller hospitals (less than 130 beds). Provision of vascular beds after CEA was associated with lower mortality (P = 0.0008) and fewer cardiac events (P = 0.03). Adherence to established clinical pathways was associated with reduced stroke and cardiac event rates while reducing CEA costs. Large SICUs (≥7 beds) and dedicated intensivists were associated with decreased mortality after CEA while a large SICU was associated with reduced stroke rate (P = 0.001). Vascular surgeons performing CEA were associated with lower stroke rates and shorter LOS (P = 0.0001) than other specialists. CAS outcomes were not influenced by specialty but costless when performed by vascular surgeons (P < 0.0001).
Structural factors affect CEA outcomes, but data on CAS were limited. These findings may inform reconfiguration of vascular services, reducing risks and costs associated with carotid interventions.
与医院组织相关的“结构因素”可能会影响手术结果。本研究旨在阐明结构因素与颈动脉内膜切除术（CEA）和颈动脉内膜切除术支架置入术（CAS）后结果之间的关系。
对 2005 年以来发表的英文研究进行系统评价。评估的结构因素如下：血管科服务的人口规模；医院床位数量；是否有专门的血管床位；既定的临床路径；外科重症监护病房（SICU）规模；外科医生/介入医生的专业。主要结果如下：死亡率；卒；心脏并发症；住院时间（LOS）；和成本。
本系统评价共纳入 11 项研究（n=95100 例患者）。对于 CEA，服务人口超过 75000 人的血管科与较低的死亡率（P<0.0001）和卒发生率（P=0.001）相关。与较小的医院（少于 130 张床位）相比，较大的医院与较低的死亡率、卒发生率和心脏事件相关。CEA 后提供血管床位与较低的死亡率（P=0.0008）和较少的心脏事件（P=0.03）相关。遵循既定的临床路径与降低卒和心脏事件发生率相关，同时降低 CEA 成本。较大的 SICU（≥7 张床）和专门的重症监护医生与 CEA 后死亡率降低相关，而较大的 SICU 与卒发生率降低相关（P=0.001）。与其他专科医生相比，进行 CEA 的血管外科医生与较低的卒发生率和较短的 LOS 相关（P=0.0001）。CAS 的结果不受专业影响，但由血管外科医生进行时成本较低（P<0.0001）。
结构因素会影响 CEA 的结果，但 CAS 的数据有限。这些发现可能为血管服务的重新配置提供信息，降低与颈动脉介入相关的风险和成本。
