Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. Electronic address: http://www.twitter.com/ZRashidMD.
Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. Electronic address: http://www.twitter.com/musaabmunir.
Surgery. 2024 Jun;175(6):1562-1569. doi: 10.1016/j.surg.2024.02.021. Epub 2024 Apr 1.
Practice fragmentation in surgery may be associated with poor quality of care. We sought to define the association between fragmented practice and outcomes in hepatopancreatic surgery relative to surgeon volume and sex.
Medicare beneficiaries who underwent hepatopancreatic surgery between 2016 and 2021 were identified. Multivariable analysis was performed to determine provider sex-based differences in the rate of fragmented practice relative to the achievement of a textbook outcome and health care expenditures after adjusting for procedure-specific case volume.
Among 37,416 patients, almost one-half were female (n = 18,333, 49.0%) with the majority treated by male surgeons (n = 33,697, 90.8%). Female surgeons were more likely to have a greater rate of fragmented practice (females: n = 242, 84.9% vs males: n = 1,487, 78.4%, P = .003; odds ratio 2.66, 95% confidence interval 2.33-3.03, P < .001). Patients treated by high rate of fragmented practice surgeons had increased odds of postoperative complications (odds ratio 1.40, 95% confidence interval 1.28-1.54), extended length-of-stay (odds ratio 1.52, 95% confidence interval 1.38-1.68), 90-day-mortality (odds ratio 1.49, 95% confidence interval 1.28-1.72), and lower odds of achieving a textbook outcome (odds ratio 0.76, 95% confidence interval 0.71-0.83). This association persisted independent of surgeon-specific volume (textbook outcome, high vs low rate of fragmented practice: high-volume surgeon, odds ratio 0.53, 95% confidence interval 0.31-0.91, P = .021 vs. low-volume surgeon, odds ratio 0.76, 95% confidence interval 0.69-0.82, P < .001). Among patients treated by male surgeons, a high rate of fragmented practice was associated with reduced odds of achieving a textbook outcome (male surgeons: odds ratio 0.76, 95% confidence interval 0.70-0.82, P < .001; female surgeons: odds ratio 0.81, 95% confidence interval 0.63-1.05, P = .110). Treatment by surgeons with higher fragmented practice was associated with higher expenditures (index expenditure: percentage difference 9.87, 95% confidence interval, 7.42-12.36; P < .05).
A high rate of fragmented practice adversely affected postoperative outcomes and healthcare expenditures even among high-volume surgeons with the impact varying based on surgeon sex.
手术中的实践碎片化可能与护理质量差有关。我们试图确定相对于外科医生数量和性别，碎片化实践与肝胰手术结果之间的关联。
确定了 2016 年至 2021 年间接受肝胰手术的 Medicare 受益人的数据。在调整了特定程序的病例量后，进行了多变量分析，以确定基于提供者性别的碎片化实践的发生率与实现教科书结果和医疗保健支出之间的差异。
在 37416 名患者中，近一半为女性（n=18333，49.0%），大多数由男性外科医生治疗（n=33697，90.8%）。女性外科医生更有可能出现更高的碎片化实践率（女性：n=242，84.9% vs 男性：n=1487，78.4%，P=0.003；优势比 2.66，95%置信区间 2.33-3.03，P<.001）。由碎片化实践率较高的外科医生治疗的患者，术后并发症的可能性增加（优势比 1.40，95%置信区间 1.28-1.54），住院时间延长（优势比 1.52，95%置信区间 1.38-1.68），90 天死亡率（优势比 1.49，95%置信区间 1.28-1.72），以及实现教科书结果的可能性降低（优势比 0.76，95%置信区间 0.71-0.83）。这种关联在独立于外科医生特定数量（教科书结果，高与低碎片化实践率：高量外科医生，优势比 0.53，95%置信区间 0.31-0.91，P=0.021 vs. 低量外科医生，优势比 0.76，95%置信区间 0.69-0.82，P<.001）的情况下仍然存在。在接受男性外科医生治疗的患者中，较高的碎片化实践率与实现教科书结果的可能性降低相关（男性外科医生：优势比 0.76，95%置信区间 0.70-0.82，P<.001；女性外科医生：优势比 0.81，95%置信区间 0.63-1.05，P=0.110）。接受具有较高碎片化实践的外科医生治疗与更高的支出相关（指数支出：百分比差异 9.87，95%置信区间，7.42-12.36；P<.05）。
即使在高量外科医生中，碎片化实践的高发生率也会对术后结果和医疗保健支出产生不利影响，其影响因外科医生的性别而异。
