最低病例数要求对腹主动脉瘤修复的管理和结果的影响。
The Effects of Minimum Caseload Requirements on Management and Outcome in Abdominal Aortic Aneurysm Repair.
机构信息
Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich; Department of Statistics, Ludwig Maximilians University Munich.
出版信息
Dtsch Arztebl Int. 2020 Oct 20;117(48):820-827. doi: 10.3238/arztebl.2020.0820.
BACKGROUND
The German quality assurance guideline on abdominal aortic aneurysm (AAA) was implemented by the Joint Federal Committee (Gemeinsamer Bundesausschuss, G-BA) in 2008. The aims of this study were to verify the association between hospital case volume and outcome and to assess the hypothetical effect of minimum caseload requirements.
METHODS
The German diagnosis-related groups statistics for the years 2012 to 2016 were scrutinized for AAA (ICD-10 GM I71.3/4) with procedure codes for endo - vascular or open surgical treatment. The primary endpoint was in-hospital mortality. Logistic regression models were used for risk adjustment, and odds ratios (OR) were calculated as a function of the annual hospital-level case volume of AAA. In a hypo - thetical approach, the linear distances for various minimum caseloads (MC) were evaluated to assess accessibility.
RESULTS
The mortality of intact AAA (iAAA) was 2.7% (men [M] 2.4%, women [W] 4.2%); ruptured AAA (rAAA), 36.9% (M 36.9%, F 37.5%). An inverse relationship between annual hospital case volume of AAA and mortality was confirmed (iAAA/rAAA: from 3.9%/51% [<10 cases/year] through 3.3%/37% [30-39 cases/year] to 1.9%/28% [≥ 75 cases/year]). For a reference category of 30 AAA procedures/year, the following significant OR were found: 10 AAA cases/year, OR 1.21 (95% confidence interval [1.20; 1.21]); 20 cases, OR 1.09 [1.09; 1.09]; 50 cases, OR 0.89 [0.89; 0.89]; 75 cases, OR 0.82 [0.82; 0.82]. In a hypothetical centralization scenario with assumed MC of 30/year, 86% of the population would have to travel less than 100 km to the nearest hospital; with an MC of 40, this would apply to only 50% (without redistribution effects).
CONCLUSION
In the observed period, a significant correlation was confirmed between high annual case volume and low in-hospital mortality. A minimum caseload requirement of 30 AAA operations/year seems reasonable in view of the accessibility of hospitals. Cite this.
背景
德国腹部主动脉瘤（AAA）质量保证指南于 2008 年由联邦联合委员会（Gemeinsamer Bundesausschuss，G-BA）实施。本研究的目的是验证医院病例量与结局之间的关系，并评估最低病例量要求的假设效果。
方法
对 2012 年至 2016 年的德国诊断相关组统计数据进行了仔细审查，AAA（ICD-10 GM I71.3/4）采用血管内或开放手术治疗的程序代码。主要终点是住院死亡率。使用逻辑回归模型进行风险调整，并计算了作为 AAA 年度医院病例量函数的优势比（OR）。在一个假设的方法中，评估了各种最低病例量（MC）的线性距离，以评估可达性。
结果
完整 AAA（iAAA）的死亡率为 2.7%（男性[M]2.4%，女性[W]4.2%）；破裂的 AAA（rAAA）为 36.9%（M 36.9%，F 37.5%）。AAA 的年度医院病例量与死亡率之间存在反比关系（iAAA/rAAA：从[10 例/年]的 3.9%/51%至[30-39 例/年]的 3.3%/37%，至[≥75 例/年]的 1.9%/28%）。对于每年 30 例 AAA 手术的参考类别，发现以下具有统计学意义的 OR：每年 10 例 AAA 手术，OR 1.21（95%置信区间[1.20；1.21]）；20 例，OR 1.09 [1.09；1.09]；50 例，OR 0.89 [0.89；0.89]；75 例，OR 0.82 [0.82；0.82]。在假设 MC 为 30/年的中心化情景下，86%的人口只需前往最近的医院少于 100 公里；而 MC 为 40 时，只有 50%（没有再分配效果）的人口适用。
结论
在观察期内，高年度病例量与低住院死亡率之间确认存在显著相关性。鉴于医院的可达性，每年 30 例 AAA 手术的最低病例量要求似乎是合理的。引用本文。
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