Manheim L M, Sohn M W, Feinglass J, Ujiki M, Parker M A, Pearce W H
Institute for Health Services Research and Policy Studies, the Division of General Internal Medicine, Northwestern University Medical School, Hines VA Hospital, Chicago, Ill 60611, USA.
J Vasc Surg. 1998 Jul;28(1):45-56; discussion 56-8. doi: 10.1016/s0741-5214(98)70199-5.
Little is known about the long-term growth and outcomes of vascular surgery procedures over time. Trends in the use of three major vascular surgery procedures by a general population-lower extremity arterial bypass (LEAB), carotid endarterectomy (CEA), and abdominal aortic aneurysm repair (AAA)-are described. The extent to which these procedures are being performed in low-, moderate-, and high-volume hospitals is examined.
California hospital discharge records for LEAB, CEA, AAA, lower extremity angioplasty, coronary angioplasty, and coronary bypass surgery (CABG) were studied in all non-federal hospitals between 1982 and 1994. The data were age- and sex-adjusted to describe procedure growth. In-hospital mortality rates for LEAB, CEA, and AAA are related to overall hospital procedure volume, using logistic regression to control for risk factors and time trends.
Growth in the number of vascular procedures performed in California was modest between 1982 and 1994, with no age-adjusted growth. Lower extremity angioplasty grew considerably in the 1980s and has since plateaued. Annual in-hospital death rates declined for all procedures except ruptured AAA. Comparing the two 5-year periods of 1982-1986 and 1990-1994, in-hospital death rates decreased from 4.2% to 3.3% for LEAB, from 9.2% to 6.2% for unruptured AAA, and from 1.6% to 1.0% for CEA (p < 0.0001). The odds of dying for patients treated in high-volume hospitals for LEAB and CEA procedures compared with patients treated in hospitals performing fewer than 20 procedures in a year were 66.7% (p = < 0.0001) and 66.1% (p < 0.0001), respectively. For patients with ruptured and unruptured AAA procedures, the odds of dying in hospitals with at least 50 AAA procedures in a year were 49.1% (p < 0.0001) and 83.8% (p = 0.016), respectively, compared with the odds of dying in low-volume hospitals.
In-hospital mortality rates for CEA, LEAB, and unruptured AAA have been significantly decreasing over time. Mortality is inversely related to hospital volume and directly related to patient age and emergency status. Mortality trends over time for ruptured AAA remains unchanged; however, mortality is less in high-volume hospitals. Coronary angioplasty (PTCA) has not had an impact on rates for LEAB.
随着时间推移，关于血管外科手术的长期生长情况及结果知之甚少。本文描述了普通人群中三种主要血管外科手术——下肢动脉搭桥术（LEAB）、颈动脉内膜切除术（CEA）和腹主动脉瘤修复术（AAA）的使用趋势。研究了这些手术在低、中、高手术量医院的开展程度。
对1982年至1994年间所有非联邦医院的加利福尼亚州医院出院记录进行研究，这些记录涉及LEAB、CEA、AAA、下肢血管成形术、冠状动脉血管成形术和冠状动脉搭桥术（CABG）。对数据进行年龄和性别调整以描述手术的增长情况。使用逻辑回归控制风险因素和时间趋势，分析LEAB、CEA和AAA的住院死亡率与医院总体手术量之间的关系。
1982年至1994年间加利福尼亚州进行的血管手术数量增长适度，经年龄调整后无增长。下肢血管成形术在20世纪80年代有显著增长，此后趋于平稳。除破裂性AAA外，所有手术的年度住院死亡率均有所下降。比较1982 - 1986年和1990 - 1994年这两个5年时间段，LEAB的住院死亡率从4.2%降至3.3%，未破裂AAA的住院死亡率从9.2%降至6.2%，CEA的住院死亡率从1.6%降至1.0%（p < 0.0001）。与每年进行少于20例手术的医院相比，在高手术量医院接受LEAB和CEA手术的患者死亡几率分别为66.7%（p = < 0.0001）和66.1%（p < 0.0001）。对于破裂性和未破裂性AAA手术患者，与低手术量医院相比，每年至少进行50例AAA手术的医院的死亡几率分别为49.1%（p < 0.0001）和83.8%（p = 0.016）。
随着时间推移，CEA、LEAB和未破裂AAA的住院死亡率显著下降。死亡率与医院手术量呈负相关，与患者年龄和急诊状态呈正相关。破裂性AAA的死亡率随时间变化趋势未变；然而，高手术量医院的死亡率较低。冠状动脉血管成形术（PTCA）对LEAB的发生率没有影响。
