The complex relationship between center volume and outcome in patients undergoing the Norwood operation.
The complex relationship between center volume and outcome in patients undergoing the Norwood operation.
复制标题
接受诺伍德手术的患者的中心体积和结果之间的复杂关系。
DOI：
10.1016/j.athoracsur.2011.07.081
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发表时间：
2012
期刊：
影响因子：
--
通讯作者：
Li,JenniferS
中科院分区：
文献类型：
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作者：
Pasquali,SaraK;Jacobs,JeffreyP;He,Xia;Hornik,ChristophP;Jaquiss,RobertDB;Jacobs,MarshallL;O'Brien,SeanM;Peterson,EricD;Li,JenniferS
背景不同中心的Norwood结果不同，先前已经描述了中心体积和结果之间的关系。目前尚不清楚这种体积-结果关系是否存在于所有级别的患者风险中，或者是否适用于所有中心。我们评估了患者风险状况对中心体积和结果之间的关系的影响，以及中心体积的差异在多大程度上解释了结果的中心间差异。方法纳入2000年至2009年接受Norwood手术的胸部外科医生学会先天性心脏病手术数据库中的婴儿。在多变量分析中评估了与年度诺伍德体积、总体和跨患者术前风险指标相关的死亡率。我们还估计了由中心体积解释的中心间死亡率变化的比例。结果队列包括来自53个中心的2557名婴儿：34个中心每年有0到10例诺伍德病例；13个中心每年有11到20例病例；6个中心每年有20例以上的病例。未调整的住院死亡率为22%。在多变量分析中，低中心容量与高死亡率相关(低容量中心与高容量中心的优势比为1.54，95%可信区间：1.02至2.32，p=0.04)。术前不同风险等级的容量-结果关系没有差异(p=0.7)。在观察到的中心间死亡率差异中，诺伍德体积可解释约14%的差异，在校正体积后，死亡率仍存在显著的中心间差异(p<；0.001)。结论中心体积与诺伍德手术后的结果有适度的相关性，与患者的风险状况无关。然而，这种关系只解释了该队列中死亡率中心间差异的一部分。
BACKGROUNDNorwood outcomes vary across centers, and a relationship between center volume and outcome has been previously described. It is unclear whether this volume-outcome relationship exists across all levels of patient risk or holds true for all centers. We evaluated the impact of patient risk status on the relationship between center volume and outcome, and the extent to which differences in center volume account for between-center variation in outcome.METHODSInfants in The Society of Thoracic Surgeons Congenital Heart Surgery Database undergoing the Norwood operation (2000 to 2009) were included. Mortality associated with annual Norwood volume overall and across patient preoperative risk tertiles was evaluated in multivariable analysis. We also estimated the proportion of between-center variation in mortality explained by center volume.RESULTSThe cohort included 2,557 infants from 53 centers: 34 centers with 0 to 10 Norwood cases per year; 13 centers with 11 to 20 cases per year; and 6 centers with more than 20 cases per year. Unadjusted in-hospital mortality was 22%. In multivariable analysis, lower center volume was associated with higher mortality (odds ratio in low-volume versus high-volume centers 1.54, 95% confidence interval: 1.02 to 2.32, p = 0.04). The volume-outcome relationship did not differ across preoperative risk tertiles (p = 0.7). Norwood volume explained an estimated 14% of the between-center variation in mortality observed, and significant between-center variation in mortality remained after adjusting for volume (p < 0.001).CONCLUSIONSCenter volume is modestly associated with outcome after the Norwood operation independent of patient risk status. However, this relationship explains only a portion of the between-center variation in mortality in this cohort.