Begg C B, Cramer L D, Hoskins W J, Brennan M F
Department of Epidemiology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
JAMA. 1998 Nov 25;280(20):1747-51. doi: 10.1001/jama.280.20.1747.
Hospitals that treat a relatively high volume of patients for selected surgical oncology procedures report lower surgical in-hospital mortality rates than hospitals with a low volume of the procedures, but the reports do not take into account length of stay or adjust for case mix.
To determine whether hospital volume was inversely associated with 30-day operative mortality, after adjusting for case mix.
Retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database in which the hypothesis was prospectively specified. Surgeons determined in advance the surgical oncology procedures for which the experience of treating a larger volume of patients was most likely to lead to the knowledge or technical expertise that might offset surgical fatalities.
All 5013 patients in the SEER registry aged 65 years or older at cancer diagnosis who underwent pancreatectomy, esophagectomy, pneumonectomy, liver resection, or pelvic exenteration, using incident cancers of the pancreas, esophagus, lung, colon, and rectum, and various genitourinary cancers diagnosed between 1984 and 1993.
Thirty-day mortality in relation to procedure volume, adjusted for comorbidity, patient age, and cancer stage.
Higher volume was linked with lower mortality for pancreatectomy (P=.004), esophagectomy (P<.001), liver resection (P=.04), and pelvic exenteration (P=.04), but not for pneumonectomy (P=.32). The most striking results were for esophagectomy, for which the operative mortality rose to 17.3% in low-volume hospitals, compared with 3.4% in high-volume hospitals, and for pancreatectomy, for which the corresponding rates were 12.9% vs 5.8%. Adjustments for case mix and other patient factors did not change the finding that low volume was strongly associated with excess mortality.
These data support the hypothesis that when complex surgical oncologic procedures are provided by surgical teams in hospitals with specialty expertise, mortality rates are lower.
与进行特定外科肿瘤手术患者数量较少的医院相比，进行此类手术患者数量相对较多的医院报告的院内手术死亡率更低，但这些报告未考虑住院时间或对病例组合进行调整。
在对病例组合进行调整后，确定医院手术量是否与30天手术死亡率呈负相关。
使用监测、流行病学和最终结果（SEER）-医疗保险链接数据库进行回顾性队列研究，其中该假设是预先设定的。外科医生预先确定了那些治疗更多患者的经验最有可能带来可能抵消手术死亡的知识或技术专长的外科肿瘤手术。
SEER登记处中所有5013名在癌症诊断时年龄在65岁及以上，接受了胰腺切除术、食管切除术、肺切除术、肝切除术或盆腔脏器清除术的患者，这些患者使用了1984年至1993年间诊断出的胰腺、食管、肺、结肠和直肠的原发性癌症以及各种泌尿生殖系统癌症。
根据合并症、患者年龄和癌症分期调整后的与手术量相关的30天死亡率。
手术量较高与胰腺切除术（P = 0.004）、食管切除术（P < 0.001）、肝切除术（P = 0.04）和盆腔脏器清除术（P = 0.04）的较低死亡率相关，但与肺切除术无关（P = 0.32）。最显著的结果是食管切除术，在手术量低的医院中手术死亡率升至17.3%，而在手术量高的医院中为3.4%；对于胰腺切除术，相应的比率分别为12.9%和5.8%。对病例组合和其他患者因素的调整并未改变手术量低与过高死亡率密切相关这一发现。
这些数据支持以下假设，即当具有专业知识的外科团队在医院进行复杂的外科肿瘤手术时，死亡率较低。
