Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. Electronic address: https://twitter.com/ZoraysM.
Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. Electronic address: https://twitter.com/HLimaSurg.
Surgery. 2023 Jun;173(6):1391-1397. doi: 10.1016/j.surg.2023.02.002. Epub 2023 Mar 10.
Familiarity with the surgical work environment has been demonstrated to improve outcomes. We sought to investigate the impact of the rate of fragmented practice on textbook outcomes, a validated composite outcome representing an "optimal" postoperative course.
Patients who underwent a hepatic or pancreatic surgical procedure between 2013 and 2017 were identified from the Medicare Standard Analytic Files. The rate of fragmented practice was defined as the surgeon's volume over the study period relative to the number of facilities practiced at. The association between the rate of fragmented practice and textbook outcomes was assessed using multivariable logistic regression.
A total of 37,599 patients were included (pancreatic: n = 23,701, 63.0%; hepatic: n = 13,898, 37.0%). After controlling for relevant characteristics, patients who underwent surgery by surgeons in higher rate of fragmented practice categories had lower odds of achieving a textbook outcome (reference: low rate of fragmented practice; intermediate rate of fragmented practice: odds ratio = 0.88 [95% confidence interval 0.84-0.93]; high rate of fragmented practice: odds ratio = 0.58 [95% confidence interval 0.54-0.61]) (both P < .001). Of note, the adverse effect of a high rate of fragmented practice on the achievement of textbook outcomes remained substantial, regardless of the county-level social vulnerability index [high rate of fragmented practice; low social vulnerability index: odds ratio = 0.58 (95% confidence interval 0.52-0.66); intermediate social vulnerability index: odds ratio = 0.56 (95% confidence interval 0.52-0.61); high social vulnerability index: odds ratio = 0.60 (95% confidence interval 0.54-0.68)] (all P < .001). Patients in intermediate and high social vulnerability index counties had 19% and 37% greater odds of undergoing surgery by a high rate of fragmented practice surgeon (reference: low social vulnerability index; intermediate social vulnerability index: odds ratio = 1.19 [95% confidence interval 1.12-1.26]; high social vulnerability index: odds ratio = 1.37 [95% confidence interval 1.28-1.46]).
Owing to the impact of the rate of fragmented practice on postoperative outcomes, decreasing fragmentation of care may be an important target for quality initiatives and a means to alleviate social disparities in surgical care.
熟悉手术工作环境已被证明可以改善手术结果。我们旨在研究碎片化手术实践的频率对教科书式结果的影响，教科书式结果是一种代表“理想”术后进程的经过验证的综合结果。
从 Medicare Standard Analytic Files 中确定了 2013 年至 2017 年间接受肝或胰腺手术的患者。碎片化手术实践的频率定义为外科医生在研究期间的手术量与手术实施的医疗机构数量的比值。使用多变量逻辑回归评估碎片化手术实践的频率与教科书式结果之间的关联。
共纳入 37599 例患者（胰腺手术：n=23701，63.0%；肝脏手术：n=13898，37.0%）。在控制了相关特征后，接受碎片化手术实践频率较高的外科医生手术的患者获得教科书式结果的可能性较低（参考：低碎片化手术实践频率；中度碎片化手术实践频率：比值比=0.88 [95%置信区间 0.84-0.93]；高碎片化手术实践频率：比值比=0.58 [95%置信区间 0.54-0.61]）（均 P<0.001）。值得注意的是，无论县级社会脆弱性指数如何，高碎片化手术实践对实现教科书式结果的不利影响仍然很大[高碎片化手术实践频率；低社会脆弱性指数：比值比=0.58（95%置信区间 0.52-0.66）；中社会脆弱性指数：比值比=0.56（95%置信区间 0.52-0.61）；高社会脆弱性指数：比值比=0.60（95%置信区间 0.54-0.68）]（均 P<0.001）。社会脆弱性指数中等和较高的县的患者接受高碎片化手术实践外科医生手术的可能性分别增加 19%和 37%（参考：低社会脆弱性指数；中等社会脆弱性指数：比值比=1.19 [95%置信区间 1.12-1.26]；高社会脆弱性指数：比值比=1.37 [95%置信区间 1.28-1.46]）。
由于碎片化手术实践对术后结果的影响，减少医疗服务的碎片化可能是质量计划的一个重要目标，也是缓解手术护理中社会差异的一种手段。
