Department of Health Policy and Management, Keio University School of Medicine, Tokyo, Japan.
Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
Surg Today. 2021 Jun;51(6):1010-1019. doi: 10.1007/s00595-021-02245-1. Epub 2021 Mar 3.
This study compared the quality of healthcare before and after implementation of a policy restructuring the healthcare delivery system and estimated the impact of centralization.
We used the National Clinical Database to study patients undergoing esophagectomies from 2011 to 2016. We compared the effect of centralization based on the patient background, surgical mortality, and year of surgery. Difference-in-difference methods based on the generalized estimating equation logistic regression model were used for before-and-after comparisons after adjusting for patient-level expected surgical mortality.
In total, 34,640 cases were identified. More cases with risk factors were noted in ultra-low-volume hospitals, where 38.4% of cases in underpopulated areas were treated, than in higher volume facilities, and the operative mortality, readmission within 30 days and length of stay were worse among patients treated in these hospitals. In centralized prefectures, the number of cases per hospital increased over time (7.2 in 2011 to 9.5 in 2016) while the crude operative mortality tended to decrease (3.4% in 2011 to 1.8% in 2016). The difference-in-difference estimator was 0.856 (95% confidence interval: 0.639-1.147, p = 0.298).
The centralization of ultra-low-volume hospitals did not lead to a deterioration in the quality of care but rather an improving trend.
本研究比较了医疗服务体系政策重构前后的医疗质量，并评估了集中化的影响。
我们使用国家临床数据库研究了 2011 年至 2016 年间接受食管切除术的患者。我们根据患者背景、手术死亡率和手术年份比较了集中化的效果。在调整患者预期手术死亡率的基础上，采用广义估计方程逻辑回归模型的差异法进行了前后比较。
共纳入 34640 例患者。在超低容量医院中，有更多风险因素的病例，其中 38.4%的人口稀少地区的病例在这些医院治疗，而在更高容量的医院中，这些医院的手术死亡率、30 天内再入院率和住院时间更差。在集中化的县，每家医院的病例数量随着时间的推移而增加（2011 年为 7.2 例，2016 年为 9.5 例），而粗手术死亡率有下降趋势（2011 年为 3.4%，2016 年为 1.8%）。差异估计值为 0.856（95%置信区间：0.639-1.147，p=0.298）。
超低容量医院的集中化并未导致医疗质量恶化，反而呈现出改善趋势。
