Kimmel S E, Berlin J A, Laskey W K
Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA.
JAMA. 1995 Oct 11;274(14):1137-42.
To assess the relationship between the volume of percutaneous transluminal coronary angioplasty (PTCA) procedures performed in a cardiac catheterization laboratory and major complications after adjusting for case mix and to evaluate the applicability of current guidelines for minimum laboratory volume.
Cohort study using the 1992 and 1993 registries of the Society for Cardiac Angiography and Interventions.
Forty-eight cardiac catheterization laboratories from throughout the United States and Canada.
All 19 594 consecutive patients without an acute myocardial infarction (MI) undergoing a first coronary balloon angioplasty.
Emergency bypass surgery, MI, or in-hospital death.
There was a significant decrease in the rates of in-hospital mortality (P = .04), emergency bypass surgery (P < .001), MI (P - .001), and major complications (defined as one or more of these outcomes; P < .001) with increasing cardiac catheterization laboratory volume. After adjustment for case mix using multivariable analysis, these associations persisted, although the association with mortality was no longer statistically significant. There was no significant difference in outcomes in laboratories performing at least 200 vs fewer than 200 procedures per year, the currently recommended minimum laboratory volume (odds ratio [OR] for major complications, 0.81; 95% confidence interval [CI], 0.53 to 1.25). However, a statistically significant decrease in major complications was observed in laboratories performing more than 400 procedures per year (adjusted OR, 0.66; 95% CI, 0.46 to 0.96; P = .03; and OR, 0.54; 95% CI, 0.38 to 0.78; P = .001) when laboratories performing 400 through 599 procedures and at least 600 procedures per year, respectively, are compared with those performing fewer than 200 per year.
An inverse association between cardiac catheterization laboratory procedure volume and major complications during PTCA exists independent of differences in patients' risk profiles. Our data suggest that the currently recommended minimum laboratory volume may be too low to distinguish higher-risk from lower-risk laboratories.
评估心脏导管实验室进行的经皮腔内冠状动脉成形术（PTCA）手术量与调整病例组合后的主要并发症之间的关系，并评估当前最低实验室手术量指南的适用性。
使用心脏血管造影和介入学会1992年和1993年登记数据进行队列研究。
来自美国和加拿大各地的48个心脏导管实验室。
所有19594例连续接受首次冠状动脉球囊成形术且无急性心肌梗死（MI）的患者。
急诊搭桥手术、MI或住院死亡。
随着心脏导管实验室手术量的增加，住院死亡率（P = 0.04）、急诊搭桥手术（P < 0.001）、MI（P = 0.001）和主要并发症（定义为这些结局中的一种或多种；P < 0.001）的发生率显著降低。使用多变量分析调整病例组合后，这些关联仍然存在，尽管与死亡率的关联不再具有统计学意义。每年进行至少200例手术与少于200例手术的实验室在结局方面无显著差异，200例是目前推荐的最低实验室手术量（主要并发症的比值比[OR]为0.81；95%置信区间[CI]为0.53至1.25）。然而，与每年进行少于200例手术的实验室相比，每年进行超过400例手术的实验室（调整后的OR为0.66；95%CI为0.46至0.96；P = 0.03；OR为0.54；95%CI为0.38至0.78；P = 0.001）主要并发症有统计学显著降低，分别将每年进行400至599例手术和至少600例手术的实验室与之比较。
心脏导管实验室手术量与PTCA期间的主要并发症之间存在负相关，且与患者风险特征的差异无关。我们的数据表明，目前推荐的最低实验室手术量可能过低，无法区分高风险和低风险实验室。
