Birkmeyer J D, Sharp S M, Finlayson S R, Fisher E S, Wennberg J E
Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, NH, USA.
Surgery. 1998 Nov;124(5):917-23.
Rates of many surgical procedures vary widely across both large and small geographic regions. Although variation in health care use has long been described, few studies have systematically compared variation profiles across surgical procedures. The goal of this study was to examine current patterns of regional variation in the rates of common surgical procedures.
The study population consisted of patients enrolled in Medicare in 1995, excluding those enrolled in risk-bearing health maintenance organizations. Patients ranged in age from 65 to 99 years. Using data from hospital discharge abstracts, we calculated rates of 11 common inpatient procedures for each of 306 US hospital referral regions (HRRs). To assess the relative variability of each procedure, we determined the number of low and high outlier regions (HRRs with rates < 50% or > 150% the national average) and the ratio of highest to lowest HRR rates.
Procedures differed markedly in their variability. Rates of hip fracture repair, resection for colorectal cancer, and cholecystectomy varied only 1.9- to 2.9-fold across HRRs (0, 0, and 4 outlier regions, respectively). Coronary artery bypass grafting, transurethral prostatectomy, mastectomy, and total hip replacement had intermediate variation profiles, varying 3.5- to 4.7-fold across regions (8, 10, 16, and 17 outlier regions, respectively). Lower extremity revascularization, carotid endarterectomy, back surgery, and radical prostatectomy had the highest variation profiles, varying 6.5- to 10.1-fold across HRRs (25, 32, 39, and 56 outlier regions, respectively).
Although the use of many surgical procedures varies widely across geographic areas, rates of "discretionary" procedures are most variable. To avoid potential overuse or underuse, efforts to increase consensus in clinical decision making should focus on these high variation procedures.
许多外科手术的发生率在大、小地理区域内差异很大。尽管长期以来人们一直在描述医疗保健使用方面的差异，但很少有研究系统地比较不同外科手术的差异情况。本研究的目的是检查常见外科手术发生率的当前区域差异模式。
研究人群包括1995年参加医疗保险的患者，不包括参加承担风险的健康维护组织的患者。患者年龄在65至99岁之间。利用医院出院摘要数据，我们计算了美国306个医院转诊区域（HRR）中每种11种常见住院手术的发生率。为了评估每种手术的相对变异性，我们确定了低和高异常值区域（发生率低于全国平均水平50%或高于150%的HRR）的数量以及最高与最低HRR发生率的比值。
手术在变异性方面有显著差异。髋部骨折修复、结直肠癌切除术和胆囊切除术的发生率在各HRR之间仅相差1.9至2.9倍（分别为0、0和4个异常值区域）。冠状动脉搭桥术、经尿道前列腺切除术、乳房切除术和全髋关节置换术的变异情况居中，各区域之间相差3.5至4.7倍（分别为8、10、16和17个异常值区域）。下肢血管重建术、颈动脉内膜切除术、背部手术和根治性前列腺切除术的变异情况最高，各HRR之间相差6.5至10.1倍（分别为25、32、39和56个异常值区域）。
尽管许多外科手术的使用在地理区域上差异很大，但“可自由选择的”手术发生率的差异最大。为避免潜在的过度使用或使用不足，在临床决策中增加共识的努力应集中在这些高变异手术上。
