Surgeon specialty and provider volumes are related to outcome of intact abdominal aortic aneurysm repair in the United States
Surgeon specialty and provider volumes are related to outcome of intact abdominal aortic aneurysm repair in the United States
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DOI：
10.1016/s0741-5214(03)00470-1
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发表时间：
2003-10-01
影响因子：
4.3
通讯作者：
Upchurch, GR
中科院分区：
文献类型：
--
作者：
Dimick, JB;Cowan, JA;Upchurch, GR
目的：本研究旨在确定外科医生专业、医院规模和外科医生数量对腹主动脉瘤 (AAA) 修复术后结局的相对重要性。方法：回顾了 1997 年全国住院患者样本中 3912 名接受 AAA 修复的患者的数据。比较了高业务量医院和低业务量医院之间以及高业务量外科医生和低业务量外科医生之间的院内死亡率。手术量大的医院每年进行超过 35 例 AAA 修复，而手术量大的外科医生每年进行超过 10 例 AAA 修复。通过分析每位外科医生执行的其他手术来确定血管、心脏和普外科专业化。结果：总体而言，AAA 修复死亡率为 4.2%，大手术量医院 (3.0%) 低于小手术量医院 (5.5%) (P < .001)。与心脏外科医生 (4.0%) 和普通外科医生 (5.5%) 相比，血管外科医生 (2.2%) 进行的手术死亡率最低 (P < .001)。与低容量医院 (5.6%) 相比，高容量医院的死亡率 (2.5%) 也较低 (P < .001)。在风险调整分析中，高通量医院、血管外科专业和高通量外科医生均与较低的院内死亡率风险独立相关。在本次分析中，高业务量医院的风险降低了 30%（95% 置信区间 [CI]，2%-51%；P < .05），高业务量外科医生的手术风险降低了 40%（95% CI，12%-60%；P =.01）。与血管外科医生相比，普通外科医生进行 AAA 修复的死亡风险高出 76%（95% CI，10%-190%；P = .02）。心脏外科医生和血管外科医生之间的死亡率没有显着差异。结论：与低数量的提供者相比，高外科医生数量和医院 AAA 修复数量均与较低的死亡率相关。血管手术专业化程度的提高与死亡率的显着降低相关，与 AAA 修复量无关。支持选择性转诊 AAA 修复的卫生政策除了提供者数量阈值外还应考虑手术专业化。
Objective: This study was undertaken to determine the relative importance of surgeon specialty, hospital volume, and surgeon volume on outcome after abdominal aortic aneurysm (AAA) repair.Methods: Data were reviewed for 3912 patients undergoing AAA repair in the Nationwide Inpatient Sample during 1997. In-hospital mortality was compared between high-volume hospitals and low-volume hospitals and between high-volume surgeons and low-volume surgeons. High-volume hospitals performed more than 35 AAA repairs per year, and high-volume surgeons performed more than 10 AAA repairs per year. Vascular, cardiac, and general surgery specialization was identified by analysis of other procedures performed by each surgeon.Results: Overall, AAA repair mortality was 4.2%, and was lower at high-volume hospitals (3.0%) than at low-volume hospitals (5.5%) (P < .001). Lowest mortality was associated with operations performed by vascular surgeons (2.2%) compared with cardiac surgeons (4.0%) and general surgeons (5.5%) (P < .001). Mortality rates were also lower for high-volume hospitals (2.5%) compared with low-volume hospitals (5.6%) (P < .001). In a risk-adjusted analysis, high-volume hospital, vascular surgery specialty, and high-volume surgeon were all independently associated with lower risk of in-hospital mortality. In this analysis, risk reduction was 30% for high-volume hospitals (95% confidence interval [CI], 2%-51%; P < .05) and 40% for surgery by a high-volume surgeon (95% CI, 12%-60%; P =.01). AAA repair by general surgeons compared with vascular surgeons was associated with 76% greater risk for death (95% CI, 10%-190%; P = .02). No significant difference in mortality was found between cardiac and vascular surgeons.Conclusions: High surgeon volume and hospital volume of AAA repair were both associated with lower mortality compared with low-volume providers. Increased specialization in vascular surgery was associated with markedly decreased mortality independent of AAA repair volume. Health policy in support of selective referral for AAA repair should consider surgical specialization in addition to provider volume thresholds.