定义加拿大安大略省肝胆管癌手术标准：基于人群的临床结局的队列研究。
Defining Standards for Hepatopancreatobiliary Cancer Surgery in Ontario, Canada: A Population-Based Cohort Study of Clinical Outcomes.
机构信息
From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright).
the Division of Head and Neck Oncology and Reconstructive Surgery, University Health Network, Toronto, Ontario, Canada (Irish).
出版信息
J Am Coll Surg. 2024 Feb 1;238(2):157-165. doi: 10.1097/XCS.0000000000000885. Epub 2023 Oct 5.
BACKGROUND
In 2006, Cancer Care Ontario created Surgical Oncology Standards for the delivery of hepatopancreatobiliary (HPB) surgery including hepatectomy and pancreaticoduodenectomy (PD). Our objective was to identify the impact of standardization on outcomes after HPB surgery in Ontario, Canada.
STUDY DESIGN
This study was a population-level analysis of patients undergoing hepatectomy or PD (2003 to 2019). Logistic regression models were used to compare 30- and 90-day mortality and length of stay (LOS) before (2003 to 2006), during (2007 to 2011), and after (2012 to 2019) standardization. Interrupted time series models were used to co-analyze secular trends.
RESULTS
A total of 7,904 hepatectomies and 5,238 PDs were performed. More than 80% of all cases were performed at a designated center (DC) before standardization. This increased to >98% in the poststandardization era. Median volumes at DCs increased from 55 to 67 hepatectomies/year and from 22 to 50 PDs/year over time. In addition, 30-day mortality after hepatectomy was 2.6% before standardization and 2.3% after standardization (p = 0.9); 30-day mortality after PD was 3.6% before standardization and 2.4% after standardization (p = 0.1). Multivariable analyses revealed a significant difference in 90-day mortality following PD poststandardization (4.3% vs 6.3%; adjusted odds ratio, 0.7; p = 0.03). Median LOS was shorter for hepatectomy (6 days vs 8 days) and PD (9 days vs 14 days; p < 0.0001) after standardization. Immediate and late effects on mortality and LOS were likely attributable to secular trends, which predated standardization.
CONCLUSIONS
Standardization was associated with a higher volume of hepatectomy and PDs with further concentration of care at DCs. Pre-existing quality initiatives may have attenuated the effect of standardization on quality outcomes. Our data highlight the merits of a multifaceted provincial system for enabling consistent access to high quality HPB care throughout a region of 15 million people over a 16-year period.
背景
2006 年，安大略癌症护理中心制定了肝胰胆管（HPB）手术的外科肿瘤学标准，包括肝切除术和胰十二指肠切除术（PD）。我们的目的是确定 HPB 手术在安大略省的标准化对结果的影响。
研究设计
这是一项对 2003 年至 2019 年期间接受肝切除术或 PD 治疗的患者进行的人群水平分析。使用逻辑回归模型比较了标准化前（2003 年至 2006 年）、标准化期间（2007 年至 2011 年）和标准化后（2012 年至 2019 年）的 30 天和 90 天死亡率和住院时间（LOS）。采用中断时间序列模型共同分析长期趋势。
结果
共进行了 7904 例肝切除术和 5238 例 PD。在标准化之前，超过 80%的病例是在指定中心（DC）进行的，在标准化之后，这一比例增加到了>98%。DC 的中位手术量从 55 例肝切除术/年增加到 67 例/年，PD 从 22 例增加到 50 例/年。此外，肝切除术的 30 天死亡率在标准化前为 2.6%，标准化后为 2.3%（p=0.9）；PD 的 30 天死亡率在标准化前为 3.6%，标准化后为 2.4%（p=0.1）。多变量分析显示，PD 术后 90 天死亡率存在显著差异，标准化后为 4.3%，标准化后为 6.3%（调整优势比，0.7；p=0.03）。肝切除术（6 天）和 PD（9 天）的住院时间缩短了，术后标准化（8 天）和术后标准化（14 天）（p<0.0001）。死亡率和 LOS 的即时和晚期影响可能归因于长期趋势，这些趋势早于标准化。
结论
标准化与肝切除术和 PD 手术的高容量相关，并且在 DC 更加集中。预先存在的质量计划可能减轻了标准化对质量结果的影响。我们的数据强调了在 16 年的时间里，为一个拥有 1500 万人口的地区提供一致的高质量 HPB 护理，建立一个多方面的省级系统的优点。
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