From the Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery (M.A.H., A.X., J.B.I., C.L.J., J.H., D.S., E.K., J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania; and Division of Trauma and Acute Care Surgery, Department of Surgery (D.N.H.), Medical College of Wisconsin, Milwaukee, Wisconsin.
J Trauma Acute Care Surg. 2022 Dec 1;93(6):786-792. doi: 10.1097/TA.0000000000003534. Epub 2022 Jan 18.
Higher center-level operative volume is associated with lower mortality after complex elective surgeries, but this relationship has not been robustly demonstrated for operative trauma. We hypothesized that trauma centers in Pennsylvania with higher operative trauma volumes would have lower risk-adjusted mortality rates than lower volume institutions.
We queried the Pennsylvania Trauma Outcomes Study database (2017-2019) for injured patients 18 years or older at Level I and II trauma centers who underwent an International Classification of Diseases, Tenth Revision (ICD-10), procedure code -defined operative procedure within 6 hours of admission. The primary exposure was tertile of center-level operative volume. The primary outcome of interest was inpatient mortality. We entered factors associated with mortality in univariate analysis (age, injury severity, mechanism, physiology) into multivariable logistic regression models with tertiles of volume accounting for center-level clustering. We conducted secondary analyses varying the form of the association between the volume and mortality to including dichotomous and fractional polynomial models.
We identified 3,650 patients at 29 centers meeting the inclusion criteria. Overall mortality was 15.9% (center-level range, 6.7-34.2%). Operative procedure types were cardiopulmonary (7.3%), vascular (20.1%), abdominopelvic (24.3%), and multiple (48.3%). The mean annual operative volume over the 3 years of data was 10 to 21 operations for low-volume centers, 22 to 47 for medium-volume centers, and 47 to 158 for high-volume centers. After controlling for patient demographics, physiology, and injury characteristics, there was no significant difference in mortality between highest and lowest tertile centers (odds ratio, 0.92; confidence interval, 0.57-1.49). Secondary analyses similarly demonstrated no relationship between center operative volume and mortality in key procedure subgroups.
In a mature trauma system, we found no association between center-level operative volume and mortality for patients who required early operative intervention for trauma. Efforts to standardize the care of seriously injured patients in Pennsylvania may ensure that even lower-volume centers are prepared to generate satisfactory outcomes.
Prognostic and Epidemiological; Level III.
在复杂的择期手术中，较高的中心手术量与死亡率降低相关，但这种关系在创伤手术中尚未得到有力证明。我们假设宾夕法尼亚州的创伤中心手术量较高，其风险调整死亡率将低于低手术量机构。
我们查询了宾夕法尼亚州创伤结果研究数据库（2017-2019 年），纳入 18 岁及以上在 I 级和 II 级创伤中心就诊的患者，这些患者在入院 6 小时内接受了国际疾病分类，第十次修订版（ICD-10）手术程序代码定义的手术操作。主要暴露因素是中心手术量的三分位数。主要观察指标是住院死亡率。我们将与死亡率相关的因素纳入单变量分析（年龄、损伤严重程度、机制、生理学），并将体积三分位数纳入考虑中心水平聚类的多变量逻辑回归模型。我们进行了二次分析，改变了体积与死亡率之间的关联形式，包括二项式和分数多项式模型。
我们在 29 个中心确定了 3650 名符合纳入标准的患者。总体死亡率为 15.9%（中心水平范围为 6.7-34.2%）。手术操作类型为心肺（7.3%）、血管（20.1%）、腹盆腔（24.3%）和多种（48.3%）。3 年数据中，平均每年手术量为 10 至 21 例的为低容量中心，22 至 47 例的为中容量中心，47 至 158 例的为高容量中心。在控制患者人口统计学、生理学和损伤特征后，最高和最低三分位数中心之间的死亡率无显著差异（比值比，0.92；置信区间，0.57-1.49）。二次分析同样表明，关键手术亚组中心手术量与死亡率之间无关联。
在一个成熟的创伤系统中，我们发现需要早期手术干预创伤的患者的中心手术量与死亡率之间没有关联。在宾夕法尼亚州努力规范严重创伤患者的护理，可能会确保即使是低容量中心也能准备好取得令人满意的结果。
预后和流行病学；三级。
