Divison of Adrenal Surgery, Department of Surgery, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, USA.
Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
Ann Surg Oncol. 2021 Dec;28(13):8849-8860. doi: 10.1245/s10434-021-10297-3. Epub 2021 Jun 17.
Subspecialization of adrenal surgery through regionalization has not been adequately evaluated. We assessed implementation of subspecialization and the association of regionalization with adrenalectomy outcomes in a community-based setting.
In this longitudinal retrospective cohort study, we used an interrupted time series analysis on consecutive adrenal surgeries at Kaiser Permanente Northern California, 2010-2019. The intervention was regionalization of surgery in 2016. Main outcomes include surgical volumes, operative time, length of stay, 30-day return-to-care, and 30-day complications obtained from the electronic medical record. t-Tests and multivariable models were used to analyze time trends in outcomes after accounting for changes in patient and disease characteristics.
In total, 850 adrenal surgery cases were eligible. Between 2010 and 2019, the annual incidence of surgery (per 100,000 persons) increased from 2.4 (95% CI 1.9-3.1) to 4.1 (95% CI 3.5-4.8). Average annual surgeon volume increased from 2.4 (95% CI 1.6-3.1) to 9.9 (95% CI 4.9-14.9), while hospital volume increased from 3.5 (95% CI 2.3-4.6) to 15.4 (95% CI 6.9-24.0). Operative time was 34 (23-45) min faster in 2018-2019 compared with 2010-2011. After regionalization, same-day discharges increased to 64% in 2019 (p < 0.0001). The frequency of return-to-care (p = 0.69) and the overall complication rate (p = 0.31) did not change.
Regionalizing adrenal surgery through surgical subspecialization and standardized care pathways was feasible and decreased operative time, and hospital stay, while increasing the frequency of same-day discharges without increasing return-to-care or complications.
通过区域化实现肾上腺手术的专业化尚未得到充分评估。我们评估了在社区环境中实施专业化和区域化与肾上腺切除术结果的关联。
在这项纵向回顾性队列研究中，我们对 2010 年至 2019 年期间 Kaiser Permanente Northern California 连续进行的肾上腺手术进行了中断时间序列分析。干预措施是 2016 年手术的区域化。主要结果包括从电子病历中获得的手术量、手术时间、住院时间、30 天内重返医疗和 30 天内并发症。在考虑患者和疾病特征变化的情况下，使用 t 检验和多变量模型分析结果的时间趋势。
共有 850 例肾上腺手术病例符合条件。2010 年至 2019 年，手术的年发病率（每 10 万人）从 2.4（95%CI 1.9-3.1）增加到 4.1（95%CI 3.5-4.8）。平均每年外科医生的手术量从 2.4（95%CI 1.6-3.1）增加到 9.9（95%CI 4.9-14.9），而医院的手术量从 3.5（95%CI 2.3-4.6）增加到 15.4（95%CI 6.9-24.0）。与 2010-2011 年相比，2018-2019 年手术时间缩短了 34 分钟（23-45 分钟）。区域化后，2019 年当天出院率增加到 64%（p <0.0001）。重返医疗的频率（p = 0.69）和总体并发症发生率（p = 0.31）没有变化。
通过外科专业知识和标准化护理途径实现肾上腺手术的区域化是可行的，可缩短手术时间和住院时间，同时增加当天出院的频率，而不会增加重返医疗或并发症的风险。
