Meuli Lorenz, Menges Anna-Leonie, Stoklasa Kerstin, Steigmiller Klaus, Reutersberg Benedikt, Zimmermann Alexander
Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland.
Department of Biostatistics at Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland.
Eur J Vasc Endovasc Surg. 2023 Apr;65(4):484-492. doi: 10.1016/j.ejvs.2022.12.009. Epub 2022 Dec 15.
To analyse the association between inter-hospital transfer and hospital mortality in patients with ruptured abdominal aortic aneurysms (rAAA) in Switzerland.
Secondary data analysis of case related hospital discharge data from the Swiss Federal Statistical Office for the years 2009 - 2018. All cases with rAAA as primary or secondary diagnosis were included. Cases with rAAA as a secondary diagnosis without surgical treatment and cases that had been transferred to another hospital without surgical treatment at the referring hospital were excluded. Logistic regression models for hospital mortality were constructed with age, sex, type of admission, van Walraven comorbidity score, type of treatment, insurance class, hospital level, and year of treatment as independent variables.
A total of 1 798 cases with rAAA were treated either surgically (62.5%) or palliatively (37.5%) in Switzerland from 1 January 2009 to 31 December 2018. Of these cases, 72.9% were treated directly (surgically or palliatively) at the hospital of first presentation, whereas 27.1% of all cases with rAAA were transferred between hospitals. The overall crude hospital mortality was 50.3%; being 23.1% in the surgically treated cohort and 95.7% in the palliatively treated cohort. Inter-hospital transfer was associated with better survival compared with patients who were admitted directly (OR 0.52; 95% CI 0.36 - 0.75; p < .001). Treatment in major hospitals was associated with significantly higher mortality rate compared with university hospitals (OR 1.98; 1.41 - 2.79; p < .001). There was no evidence of an association between open repair and hospital mortality (OR 1.06; 0.77 - 1.48; p = .72) compared with endovascular repair.
In a healthcare system such as Switzerland's with a highly specialised rescue chain, transfer of haemodynamically stable patients with rAAA is probably safe. In this setting, centralised medical care might outweigh the potential disadvantages of a short delay due to patient transfer. Further studies are needed to address potential confounding factors such as haemodynamic and anatomical features.
分析瑞士腹主动脉瘤破裂（rAAA）患者的院间转运与医院死亡率之间的关联。
对瑞士联邦统计局2009年至2018年与病例相关的医院出院数据进行二次数据分析。纳入所有以rAAA作为主要或次要诊断的病例。排除以rAAA作为次要诊断但未接受手术治疗的病例，以及在转诊医院未接受手术治疗就被转至另一家医院的病例。以年龄、性别、入院类型、范瓦尔雷文合并症评分、治疗类型、保险类别、医院级别和治疗年份作为自变量，构建医院死亡率的逻辑回归模型。
2009年1月1日至2018年12月31日期间，瑞士共有1798例rAAA患者接受了手术治疗（62.5%）或姑息治疗（37.5%）。在这些病例中，72.9%在首次就诊医院直接接受了治疗（手术治疗或姑息治疗），而所有rAAA病例中有27.1%在医院之间进行了转运。总体粗医院死亡率为50.3%；手术治疗队列中的死亡率为23.1%，姑息治疗队列中的死亡率为95.7%。与直接入院的患者相比，院间转运与更好的生存率相关（比值比0.52；95%置信区间0.36 - 0.75；p <.001）。与大学医院相比，在大型医院接受治疗的死亡率显著更高（比值比1.98；1.41 - 2.79；p <.001）。与血管内修复相比，未发现开放修复与医院死亡率之间存在关联（比值比1.06；0.77 - 1.48；p = 0.72）。
在瑞士这样拥有高度专业化救援链的医疗体系中，血流动力学稳定的rAAA患者的转运可能是安全的。在这种情况下，集中医疗护理可能超过因患者转运导致的短暂延迟带来的潜在不利影响。需要进一步研究以解决血流动力学和解剖学特征等潜在混杂因素。
