Jenkins K J, Newburger J W, Lock J E, Davis R B, Coffman G A, Iezzoni L I
Department of Cardiology, Children's Hospital, Boston, MA 02115.
Pediatrics. 1995 Mar;95(3):323-30.
To examine the impact of hospital caseload on in-hospital mortality for pediatric congenital heart surgery.
Population-based, retrospective cohort study.
Acute care hospitals in California and Massachusetts.
Children undergoing surgery for congenital heart disease, identified by the presence of procedure codes indicating surgical repair of a congenital heart defect in computerized statewide hospital discharge abstract databases. Cases were grouped into four categories based on the complexity of the procedure.
Adjusted odds ratios (OR) for in-hospital death were estimated using generalized estimating equations that account for the intra-institutional correlation among patients.
A total of 2833 cases at 37 centers were identified. Compared with centers performing > 300 cases per year, after controlling for patient characteristics, centers performing < 10 cases per year had an OR for in-hospital death of 7.7 (95% confidence interval (CI) [1.6-37.8]); 10 to 100 cases, OR = 2.9 (95% CI [1.6-5.3]); 101 to 300 cases, OR = 3.0 (95% CI [1.8-4.9]). Independent risk factors for mortality included procedure complexity category (P < .0001), use of cardiopulmonary bypass (P < .0001), young age at surgery (P = .001), and transfer from another acute care hospital (P < .0001). Few differences were found by hospital caseload in length of stay or total hospital charges.
For children with a congenital heart defect who underwent surgery in California in 1988 or Massachusetts in 1989, the risk of dying in-hospital was much lower if the surgery was performed at an institution performing > 300 cases annually. This study was limited by the absence of clinical detail in discharge abstract databases. If these findings are corroborated by other studies, health care delivery strategies that direct children requiring surgical correction of congenital heart defects to high-volume centers may substantially reduce overall mortality.
探讨医院病例数量对小儿先天性心脏病手术院内死亡率的影响。
基于人群的回顾性队列研究。
加利福尼亚州和马萨诸塞州的急症医院。
接受先天性心脏病手术的儿童，通过计算机化的全州医院出院摘要数据库中表明先天性心脏缺陷手术修复的程序代码来识别。病例根据手术复杂性分为四类。
使用考虑患者机构内相关性的广义估计方程估计院内死亡的调整比值比（OR）。
共识别出37个中心的2833例病例。与每年进行超过300例手术的中心相比，在控制患者特征后，每年进行少于10例手术的中心院内死亡的OR为7.7（95%置信区间[CI][1.6 - 37.8]）；10至100例，OR = 2.9（95%CI[1.6 - 5.3]）；101至300例，OR = 3.0（95%CI[1.8 - 4.9]）。死亡的独立危险因素包括手术复杂性类别（P <.0001）、体外循环的使用（P <.0001）、手术时年龄小（P =.001）以及从另一家急症医院转诊（P <.0001）。在住院时间或总住院费用方面，按医院病例数量几乎未发现差异。
对于1988年在加利福尼亚州或1989年在马萨诸塞州接受手术的先天性心脏缺陷儿童，如果手术在每年进行超过300例手术的机构进行，院内死亡风险要低得多。本研究因出院摘要数据库中缺乏临床细节而受到限制。如果这些发现得到其他研究的证实，将需要手术矫正先天性心脏缺陷的儿童转诊至手术量大的中心的医疗服务提供策略可能会大幅降低总体死亡率。
