The CABG surgery volume-outcome relationship: Temporal trends and selection effects in California, 1998-2004
The CABG surgery volume-outcome relationship: Temporal trends and selection effects in California, 1998-2004
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DOI：
10.1111/j.1475-6773.2007.00740.x
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发表时间：
2008-02-01
影响因子：
3.4
通讯作者：
Romano, Patrick S.
中科院分区：
文献类型：
--
作者：
Marcin, James P.;Li, Zhongmin;Romano, Patrick S.
Objective.研究1998年至2004年加州冠状动脉旁路移植术（CABG）手术量-结果关系的时间趋势，并通过使用自愿和强制性医院报告期间的数据评估选择对这种关系的影响。我们使用了1998年至2002年加州CABG死亡率报告项目（CCMRP，一个由68至81家医院自愿报告的项目）和2003年至2004年加州CABG结果报告项目（CCORP，一个由121至120家医院强制报告的项目）收集的患者水平的临床数据。患者是主要分析单位，院内死亡率是主要结局。我们使用分层逻辑回归模型（广义线性混合模型）来评估医院年容量与医院死亡率的相关性，同时控制7年中每一年的详细患者水平协变量。所有的数据都被系统地收集，准确性审查，并由加州的全州卫生规划和发展办公室（OSHPD）的状态验证。我们发现，在医院自愿报告期间，（1998-2002年），除1998年外，高容量医院的风险调整院内死亡率平均比低容量医院低（1998年每100例手术的比值比[OR]=0.962，95%置信区间[CI]：0.912-1.015; 1999年OR=0.955，95% CI：0.920-0.991; 2000年OR=0.942，95%CI：0.897-0.989; 2001年OR=0.935，95%CI：0.887-0.986; 2002年OR=0.946，95%CI：0.899-0.997）。我们还发现，在强制报告期内，（2003年和2004年）没有数量-结果关系（2003年OR=0.997，95%CI：0.939-1.058; 2004年OR=0.984，95%CI：0.915-1.058），这种关联性的缺乏并不是由于在志愿者项目中添加了最初没有贡献的医院的数据而导致的报告偏倚。在加州，没有州法规支持CABG手术的区域化，1998年至2002年存在较弱的量-结果关系，但在2003年和2004年不存在。容量-结果相关性的消失与全州范围内强制性CABG手术报告程序的实施在时间上相关。
Objective. To investigate the temporal trends in the volume-outcome relationship in coronary artery bypass graft (CABG) surgery in California from 1998 to 2004, and to assess the selection effects on this relationship by using data from periods of voluntary and mandatory hospital reporting.Data Sources. We used patient-level clinical data collected for the California CABG Mortality Reporting Program (CCMRP, a voluntary reporting program with between 68 and 81 hospitals) from 1998 to 2002 and the California CABG Outcomes Reporting Program (CCORP, a mandatory reporting program with 121 and 120 hospitals) from 2003 to 2004.Study Design. The patient was the primary unit of analysis, and in-hospital mortality was the primary outcome. We used hierarchical logistic regression models (generalized linear mixed models) to assess the association of hospital annual volume with hospital mortality while controlling for detailed patient-level covariates in each of the 7 years.Data Collection Methods. All data were systematically collected, reviewed for accuracy, and validated by the State of California's Office of Statewide Health Planning and Development (OSHPD).Principal Findings. We found that during the period of voluntary hospital reporting (1998-2002), with the exception of 1998, higher volume hospitals had significantly lower risk-adjusted in-hospital mortality rates, on average, than lower volume hospitals (1998 odds ratio [OR] per 100 operations performed=0.962, 95 percent confidence interval [CI]: 0.912-1.015; 1999 OR=0.955, 95 percent CI: 0.920-0.991; 2000 OR=0.942, 95 percent CI: 0.897-0.989; 2001 OR=0.935, 95 percent CI: 0.887-0.986; 2002 OR=0.946, 95 percent CI: 0.899-0.997). We also found that in the period of mandatory reporting (2003 and 2004) there was no volume-outcome relationship (2003 OR=0.997, 95 percent CI: 0.939-1.058; 2004 OR=0.984, 95 percent CI: 0.915-1.058) and that this lack of association was not due to a reporting bias from the addition of data from hospitals that did not originally contribute during the voluntary program.Conclusions. In California, where no state regulations support regionalization of CABG surgeries, a weak volume-outcome relationship was present from 1998 to 2002, but was absent in 2003 and 2004. The disappearance of the volume-outcome association was temporally related to the implementation of a statewide mandatory CABG surgery reporting program.