全州范围内胰十二指肠切除术的区域化及其对住院死亡率的影响。
Statewide regionalization of pancreaticoduodenectomy and its effect on in-hospital mortality.
作者信息
Gordon T A, Bowman H M, Tielsch J M, Bass E B, Burleyson G P, Cameron J L
机构信息
Johns Hopkins Hospital, Baltimore, MD, USA.
出版信息
Ann Surg. 1998 Jul;228(1):71-8. doi: 10.1097/00000658-199807000-00011.
OBJECTIVE
This study examined a statewide trend in Maryland toward regionalization of pancreaticoduodenectomy over a 12-year period and its effect on statewide in-hospital mortality rates for this procedure.
SUMMARY BACKGROUND DATA
Previous studies have demonstrated that the best outcomes are achieved in centers performing large numbers of pancreaticoduodenectomies, which suggests that regionalization could lower the overall in-hospital mortality rate for this procedure.
METHODS
Maryland state hospital discharge data were used to select records of patients undergoing a pancreaticoduodenectomy between 1984 and 1995. Hospitals were classified into high-volume and low-volume provider groups. Trends in surgical volume and mortality rates were examined by provider group and for the entire state. Regression analyses were used to examine whether hospital share of pancreaticoduodenectomies was a significant predictor of the in-hospital mortality rate, adjusting for study year and patient characteristics. The portion of the decline in the statewide in-hospital mortality rate for this procedure attributable to the high-volume provider's increasing share was determined.
RESULTS
A total of 795 pancreaticoduodenectomies were performed in Maryland at 43 hospitals from 1984 to 1995 (Maryland residents only). During this period, one institution increased its yearly share of pancreaticoduodenectomies from 20.7% to 58.5%, and the statewide in-hospital mortality rate for the procedure decreased from 17.2% to 4.9%. After adjustment for patient characteristics and study year, hospital share remained a significant predictor of mortality. An estimated 61% of the decline in the statewide in-hospital mortality rate for the procedure was attributable to the increase in share of discharges at the high-volume provider.
CONCLUSIONS
A trend toward regionalization of pancreaticoduodenectomy over a 12-year period in Maryland was associated with a significant decrease in the statewide in-hospital mortality rate for this procedure, demonstrating the effectiveness of regionalization for high-risk surgery.
目的
本研究调查了马里兰州在12年期间胰十二指肠切除术区域化的全州趋势及其对该手术全州住院死亡率的影响。
总结背景数据
先前的研究表明，在进行大量胰十二指肠切除术的中心可取得最佳疗效，这表明区域化可降低该手术的总体住院死亡率。
方法
利用马里兰州医院出院数据选取1984年至1995年间接受胰十二指肠切除术患者的记录。医院被分为高手术量和低手术量医疗服务提供者组。按医疗服务提供者组和全州范围检查手术量和死亡率趋势。采用回归分析来检验胰十二指肠切除术的医院占比是否是住院死亡率的显著预测因素，并对研究年份和患者特征进行调整。确定该手术全州住院死亡率下降中归因于高手术量医疗服务提供者占比增加的部分。
结果
1984年至1995年期间，马里兰州43家医院共进行了795例胰十二指肠切除术（仅马里兰州居民）。在此期间，一家机构将其每年的胰十二指肠切除术占比从20.7%提高到58.5%，该手术的全州住院死亡率从17.2%降至4.9%。在对患者特征和研究年份进行调整后，医院占比仍然是死亡率的显著预测因素。该手术全州住院死亡率下降的估计61%归因于高手术量医疗服务提供者出院占比的增加。
结论
马里兰州在12年期间胰十二指肠切除术区域化的趋势与该手术全州住院死亡率的显著下降相关，证明了区域化对高风险手术的有效性。
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