Zhang Chi, Hanson Kristine, Sangaralingham Lindsey, Van Houten Holly K, Fong Zhi, Chang Yu-Hui, Kendrick Michael, Etzioni David, Habermann Elizabeth, Thiels Cornelius
Department of Surgery, Mayo Clinic Arizona, Phoenix.
Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Rochester, Rochester, Minnesota.
JAMA Netw Open. 2025 Jul 1;8(7):e2524165. doi: 10.1001/jamanetworkopen.2025.24165.
Identification of factors associated with variation in outpatient surgery may further quality improvement efforts to safely reduce postoperative hospital length of stay nationally.
To explore variation in the use of outpatient surgery, incorporating patient, geographic, and hospital factors.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cross-sectional study used deidentified administrative claims data from OptumLabs Data Warehouse. Participants included adults who underwent 1 of 10 general, urological, or gynecological operations between January 1, 2015, and June 30, 2021, in the US. Patients who underwent combined procedures or reoperations or had at least 15 Elixhauser comorbidities were excluded. Data were analyzed from July 26 to December 16, 2023.
Inpatient or outpatient surgical procedures.
Multilevel logistic regression assessed variation in the use of outpatient surgery rates by hospital characteristics (bed size, presence of trainees, and rural referral center status) and hospital census division, adjusting for patient factors (age, sex, number of Elixhauser comorbidities, year, and rural-urban commuting area). This multilevel model allowed for the sources of variability to be quantitatively attributed to patient characteristics, geography, and hospital characteristics.
A total of 330 424 (72.3%) of 456 954 included patients underwent outpatient surgery. The median age was 54 (IQR, 41-67) years, and of those with data available, most patients were female (268 692 of 414 193 [64.9%]). The likelihood of outpatient surgery varied significantly by hospital census division for all 10 operations (eg, MIS salpingo-oophorectomy range, 29.6%-58.8%; P < .001). Variation in hospital census division contributed most to outpatient surgery for 8 of 10 operations compared with other patient and hospital characteristics. Hospital census division contributed the greatest degree to the variation in outpatient simple mastectomy (20.6%) and the least to outpatient open ventral hernia repair (0.7%). Multivariable analysis showed that the odds of outpatient surgery for patients from metropolitan areas were higher for minimally invasive salpingo-oophorectomy (odds ratio [OR], 1.62; 95% CI, 1.34-1.95) and open ventral hernia repair (OR, 1.16; 95% CI, 1.09-1.24). Hospitals with 400 or more beds were independently associated with decreased odds of outpatient surgery compared with hospitals with 50 to 199 beds for 4 of 7 operations (MIS paraesophageal hernia repair [OR, 0.58; 95% CI, 0.47-0.71; P < .001]; MIS cholecystectomy [OR, 0.73; 95% CI, 0.68-0.78; P < .001]; open ventral hernia [OR, 0.51; 95% CI, 0.46-0.57; P < .001]; MIS ventral hernia repair [OR, 0.66; 95% CI, 0.56-0.77; P < .001]). The presence of a residency training program was independently associated with increased odds of outpatient surgery for simple mastectomy (OR, 1.35; 95% CI, 1.16-1.58; P < .001) and mastectomy with reconstruction (OR, 1.50; 95% CI, 1.27-1.77; P < .001) and decreased odds of outpatient surgery for minimally invasive cholecystectomy (OR, 0.96; 95% CI, 0.92-1.00; P = .04), open ventral hernia repair (OR, 0.93; 95% CI, 0.86-1.00; P = .04), and total thyroidectomy (OR, 0.84; 95% CI, 0.71-1.00; P = .04).
In this cross-sectional study, significant variation existed in the use of outpatient surgery in the US and appeared to be driven primarily by hospital geography. Addressing these variations may improve the use of resources.
识别与门诊手术差异相关的因素，可能会进一步推动全国范围内旨在安全缩短术后住院时间的质量改进工作。
探讨门诊手术使用情况的差异，纳入患者、地理和医院因素。
设计、设置和参与者：这项回顾性横断面研究使用了OptumLabs数据仓库中去识别化的行政索赔数据。参与者包括2015年1月1日至2021年6月30日期间在美国接受10种普通、泌尿外科或妇科手术之一的成年人。接受联合手术或再次手术或至少有15种埃利克斯豪泽合并症的患者被排除。数据于2023年7月26日至12月16日进行分析。
住院或门诊手术程序。
多水平逻辑回归评估了按医院特征（床位规模、是否有实习生以及农村转诊中心状态）和医院普查分区划分的门诊手术率差异，并对患者因素（年龄、性别、埃利克斯豪泽合并症数量、年份以及城乡通勤区域）进行了调整。这种多水平模型允许将变异性来源定量归因于患者特征、地理和医院特征。
在纳入的456954例患者中，共有330424例（72.3%）接受了门诊手术。中位年龄为54岁（四分位间距，41 - 67岁），在有可用数据的患者中，大多数为女性（414193例中的268692例[64.9%]）。对于所有10种手术，门诊手术的可能性在不同医院普查分区存在显著差异（例如，腹腔镜输卵管卵巢切除术范围为29.6% - 58.8%；P <.001）。与其他患者和医院特征相比，医院普查分区的差异对10种手术中的8种门诊手术贡献最大。医院普查分区对门诊单纯乳房切除术差异的贡献最大（20.6%），对门诊开放性腹疝修补术差异的贡献最小（0.7%）。多变量分析显示，来自大都市地区的患者接受微创输卵管卵巢切除术（优势比[OR]，1.62；95%置信区间，1.34 - 1.95）和开放性腹疝修补术（OR，1.16；95%置信区间，1.09 - 1.24）的门诊手术几率更高。与拥有50至199张床位的医院相比，拥有400张或更多床位的医院在7种手术中的4种（腹腔镜食管旁疝修补术[OR，0.58；95%置信区间，0.47 - 0.71；P <.001]；腹腔镜胆囊切除术[OR，0.73；95%置信区间，0.68 - 0.78；P <.001]；开放性腹疝[OR，0.51；95%置信区间，0.46 - 0.57；P <.001]；腹腔镜腹疝修补术[OR，0.66；95%置信区间，0.56 - 0.77；P <.001]）中，门诊手术几率独立降低。存在住院医师培训项目与单纯乳房切除术（OR，1.35；95%置信区间，1.16 - 1.58；P <.001）和乳房切除重建术（OR，1.50；95%置信区间，1.27 - 1.77；P <.001）的门诊手术几率增加独立相关，而与微创胆囊切除术（OR，0.96；95%置信区间，0.92 - 1.00；P = 0.04）、开放性腹疝修补术（OR，0.93；95%置信区间，0.86 - 1.00；P = 0.04）和全甲状腺切除术（OR，0.84；95%置信区间，0.71 - 1.00；P = 0.04）的门诊手术几率降低独立相关。
在这项横断面研究中，美国门诊手术的使用存在显著差异，且似乎主要由医院地理位置驱动。解决这些差异可能会改善资源利用情况。
