Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.
JAMA Surg. 2021 May 1;156(5):479-487. doi: 10.1001/jamasurg.2021.0135.
Intraoperative anesthesiology care is crucial to high-quality surgical care. The clinical expertise and experience of anesthesiologists may decrease the risk of adverse outcomes.
To examine the association between anesthesiologist volume and short-term postoperative outcomes for complex gastrointestinal (GI) cancer surgery.
DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study used administrative health care data sets from various data sources in Ontario, Canada. Adult patients who underwent esophagectomy, pancreatectomy, or hepatectomy for GI cancer from January 1, 2007, to December 31, 2018, were eligible. Patients with an invalid identification number, a duplicate surgery record, and missing primary anesthesiologist information were excluded.
Primary anesthesiologist volume was defined as the annual number of procedures of interest (esophagectomy, pancreatectomy, and hepatectomy) supported by that anesthesiologist in the 2 years before the index surgery. Volume was dichotomized into low-volume and high-volume categories, with 75th percentile or 6 or more procedures per year selected as the cutoff point.
The primary outcome was a composite of 90-day major morbidity (with a Clavien-Dindo classification grade 3-5) and readmission. Secondary outcomes were individual components of the primary outcome. The association between exposure and outcomes was examined using multivariable logistic regression models, accounting for potential confounders.
Of the 8096 patients included, 5369 were men (66.3%) and the median (interquartile range [IQR]) age was 65 (57-72) years. Operations were supported by 842 anesthesiologists and performed by 186 surgeons, and the median (IQR) anesthesiologist volume was 3 (1.5-6) procedures per year. A total of 2166 patients (26.7%) received care from high-volume anesthesiologists. Primary outcome occurred in 36.3% of patients in the high-volume group and 45.7% of patients in the low-volume group. After adjustment, care by high-volume anesthesiologists was independently associated with lower odds of the primary outcome (adjusted odds ratio [aOR], 0.85; 95% CI, 0.76-0.94), major morbidity (aOR, 0.83; 95% CI, 0.75-0.91), unplanned intensive care unit admission (aOR, 0.84; 95% CI, 0.76-0.94), but not readmission (aOR, 0.87; 95% CI, 0.73-1.05) or mortality (aOR, 1.05; 95% CI, 0.84-1.31). E-values analysis indicated that an unmeasured variable would unlikely substantively change the observed risk estimates.
This study found that, among adults who underwent complex gastrointestinal cancer surgery, those who received care from high-volume anesthesiologists had a lower risk of adverse postoperative outcomes compared with those who received care from low-volume anesthesiologists. These findings support organizing perioperative care to increase anesthesiologist volume to optimize patient outcomes.
术中麻醉护理对于高质量的手术护理至关重要。麻醉师的临床专业知识和经验可能会降低不良结果的风险。
研究复杂胃肠道 (GI) 癌症手术中麻醉师数量与短期术后结果之间的关联。
设计、设置和参与者：本基于人群的队列研究使用了来自加拿大安大略省多个数据源的行政医疗保健数据集。符合条件的患者为 2007 年 1 月 1 日至 2018 年 12 月 31 日期间接受 GI 癌症食管切除术、胰腺切除术或肝切除术的成年人。排除了识别号码无效、手术记录重复和主要麻醉师信息缺失的患者。
主要麻醉师数量定义为该麻醉师在索引手术前 2 年内支持的感兴趣手术（食管切除术、胰腺切除术和肝切除术）的年手术量。将数量分为低数量和高数量两类，选择第 75 百分位数或每年 6 次或以上作为截止点。
主要结果是 90 天主要发病率（Clavien-Dindo 分级 3-5）和再入院的复合结果。次要结果是主要结果的各个组成部分。使用多变量逻辑回归模型检查暴露与结果之间的关联，同时考虑了潜在的混杂因素。
在纳入的 8096 名患者中，5369 名男性（66.3%），中位（四分位距 [IQR]）年龄为 65（57-72）岁。手术由 842 名麻醉师支持，由 186 名外科医生进行，中位（IQR）麻醉师数量为每年 3（1.5-6）次。共有 2166 名患者（26.7%）接受了高容量麻醉师的治疗。高容量组中有 36.3%的患者发生了主要结果，低容量组中有 45.7%的患者发生了主要结果。调整后，高容量麻醉师提供的护理与较低的主要结果（调整后的优势比 [aOR]，0.85；95%CI，0.76-0.94）、主要发病率（aOR，0.83；95%CI，0.75-0.91）、非计划入住重症监护病房（aOR，0.84；95%CI，0.76-0.94）相关，但与再入院（aOR，0.87；95%CI，0.73-1.05）或死亡率（aOR，1.05；95%CI，0.84-1.31）无关。E 值分析表明，未测量的变量不太可能实质性地改变观察到的风险估计值。
这项研究发现，在接受复杂胃肠道癌症手术的成年人中，与接受低容量麻醉师治疗的患者相比，接受高容量麻醉师治疗的患者术后不良结果的风险较低。这些发现支持组织围手术期护理以增加麻醉师数量，从而优化患者的结果。
