Hannan E L, Popp A J, Tranmer B, Fuestel P, Waldman J, Shah D
Department of Health Policy, Management, and Behavior, State University of New York, University at Albany School of Public Health, Albany Medical College, NY, USA.
Stroke. 1998 Nov;29(11):2292-7. doi: 10.1161/01.str.29.11.2292.
The objective of this study was to assess the relationship between each of 2 provider volume measures for carotid endarterectomies (CEs) (annual hospital volume and annual surgeon volume) and in-hospital mortality. New York's Statewide Planning and Research (SPARCS) administrative database was used to identify all 28 207 patients for whom carotid endarterectomy was the principal procedure performed in New York State hospitals between January 1, 1990, and December 31, 1995.
A statistical model was developed to predict in-hospital mortality using age, admission status, and several conditions found to be associated with higher-than-average mortality. This model was then used to calculate risk-adjusted mortality rates for various intersections of hospital and surgeon volume ranges.
Risk-adjusted in-hospital mortality ranged from 1.96% (95% confidence interval, 1.47 to 2.57) for patients having surgeons with annual CE volumes of <5 in hospitals with annual CE volumes of </=100 to 0.94% (95% confidence interval, 0.73 to 1.19) for patients having surgeons with annual volumes of >/=5 in hospitals with annual CE volumes of >100. These 2 rates were statistically different.
We conclude that the in-hospital mortality rates for carotid endarterectomies performed by surgeons with extremely low annual volumes (<5) and for hospitals with low volumes (</=100) are significantly higher than the in-hospital rates of higher-volume surgeons and hospitals, even after taking preprocedural patient severity of illness into account.
本研究的目的是评估颈动脉内膜切除术（CE）的两种医疗服务提供者手术量指标（年度医院手术量和年度外科医生手术量）与住院死亡率之间的关系。利用纽约州全州规划与研究（SPARCS）行政数据库，确定了1990年1月1日至1995年12月31日期间在纽约州医院接受颈动脉内膜切除术作为主要手术的所有28207例患者。
建立一个统计模型，使用年龄、入院状态以及其他一些被发现与高于平均死亡率相关的疾病来预测住院死亡率。然后使用该模型计算不同医院手术量范围和外科医生手术量范围交叉情况下的风险调整死亡率。
风险调整后的住院死亡率范围为：在年度CE手术量≤100的医院中，年度CE手术量＜5的外科医生所治疗患者的死亡率为1.96%（95%置信区间为1.47%至2.57%）；在年度CE手术量＞100的医院中，年度手术量≥5的外科医生所治疗患者的死亡率为0.94%（95%置信区间为0.73%至1.19%）。这两个比率在统计学上存在差异。
我们得出结论，即使考虑到术前患者的疾病严重程度，年度手术量极低（＜5）的外科医生以及手术量低（≤100）的医院所进行的颈动脉内膜切除术的住院死亡率，显著高于手术量较高的外科医生和医院的住院死亡率。
