Association Between Anesthesiologist Volume and Short-term Outcomes in Complex Gastrointestinal Cancer Surgery
Association Between Anesthesiologist Volume and Short-term Outcomes in Complex Gastrointestinal Cancer Surgery
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DOI：
10.1001/jamasurg.2021.0135
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发表时间：
2021-03-17
期刊：
影响因子：
16.9
通讯作者：
Sutradhar, Rinku
中科院分区：
文献类型：
--
作者：
Hallet, Julie;Jerath, Angela;Sutradhar, Rinku
术中麻醉护理是高质量手术护理的关键。麻醉医师的临床专业知识和经验可以降低不良后果的风险。目的探讨复杂胃肠道（GI）肿瘤手术麻醉医师容积与术后短期预后的关系。设计、环境和参与者本基于人群的队列研究使用了来自加拿大安大略省各种数据源的行政卫生保健数据集。2007年1月1日至2018年12月31日期间因胃肠道癌接受食管切除术、胰腺切除术或肝切除术的成年患者纳入研究。排除无效的身份证号、重复的手术记录和缺少初级麻醉医师信息的患者。初级麻醉医师量的定义是该麻醉师在首次手术前2年内每年进行的感兴趣的手术（食管切除术、胰腺切除术和肝切除术）的数量。将体积分为小体积和大体积两类，每年选择第75个百分位数或6个或更多的手术作为分界点。主要结局和测量主要结局是90天主要发病率（Clavien-Dindo分级为3-5）和再入院的综合结果。次要结局是主要结局的个别组成部分。使用多变量逻辑回归模型检查暴露与结果之间的关系，并考虑潜在的混杂因素。结果纳入的8096例患者中，男性5369例（66.3%），中位年龄（四分位间距[IQR）为65（57-72）岁。842名麻醉师支持手术，186名外科医生执行手术，麻醉师数量中位数（IQR）为每年3例（1.5-6）例。共有2166名患者（26.7%）接受了高容量麻醉医师的护理。大容量组36.3%的患者出现了主要结局，小容量组45.7%的患者出现了主要结局。调整后，大容量麻醉师的护理与主要结局（校正优势比[a0R]， 0.85; 95% CI, 0.76-0.94）、主要发病率（aOR, 0.83; 95% Cl. 0.75-0.91）、非计划重症监护病房入院（aOR, 0.84; 95% Cl. 0.76-0.94）、再入院（a0R, 0.87; 95% CI, 0.73-1.05）或死亡率（a0R, 1.05; 95% CI, 0.84-1.31）的低几率独立相关。e值分析表明，未测量的变量不太可能实质性地改变观察到的风险估计。结论和相关性本研究发现，在接受复杂胃肠道肿瘤手术的成人中，与接受小剂量麻醉医师护理的患者相比，接受大剂量麻醉医师护理的患者术后不良预后的风险较低。这些发现支持组织围手术期护理以增加麻醉师数量以优化患者预后。
IMPORTANCE Intraoperative anesthesiology care is crucial to high-quality surgical care. The clinical expertise and experience of anesthesiologists may decrease the risk of adverse outcomes.OBJECTIVE To examine the association between anesthesiologist volume and short-term postoperative outcomes for complex gastrointestinal (GI) cancer surgery.DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study used administrative health care data sets from various data sources in Ontario, Canada. Adult patients who underwent esophagectomy, pancreatectomy, or hepatectomy for GI cancer from January 1, 2007, to December 31, 2018, were eligible. Patients with an invalid identification number, a duplicate surgery record, and missing primary anesthesiologist information were excluded.EXPOSURES Primary anesthesiologist volume was defined as the annual number of procedures of interest (esophagectomy, pancreatectomy, and hepatectomy) supported by that anesthesiologist in the 2 years before the index surgery. Volume was dichotomized into low-volume and high-volume categories, with 75th percentile or 6 or more procedures per year selected as the cutoff point.MAIN OUTCOME AND MEASURES The primary outcome was a composite of 90-day major morbidity (with a Clavien-Dindo classification grade 3-5) and readmission. Secondary outcomes were individual components of the primary outcome. The association between exposure and outcomes was examined using multivariable logistic regression models, accounting for potential confounders.RESULTS Of the 8096 patients included, 5369 were men (66.3%) and the median (interquartile range [IQR)) age was 65 (57-72) years. Operations were supported by 842 anesthesiologists and performed by 186 surgeons, and the median (IQR) anesthesiologist volume was 3 (1.5-6) procedures per year. A total of 2166 patients (26.7%) received care from high-volume anesthesiologists. Primary outcome occurred in 36.3% of patients in the high-volume group and 45.7% of patients in the low-volume group. After adjustment, care by high-volume anesthesiologists was independently associated with lower odds of the primary outcome (adjusted odds ratio [a0R], 0.85; 95% CI, 0.76-0.94), major morbidity (aOR, 0.83; 95% Cl. 0.75-0.91), unplanned intensive care unit admission (a OR, 0.84; 95% Cl. 0.76-0.94), but not readmission (a0R, 0.87; 95% CI, 0.73-1.05) or mortality (a0R, 1.05; 95% CI, 0.84-1.31). E-values analysis indicated that an unmeasured variable would unlikely substantively change the observed risk estimates.CONCLUSIONS AND RELEVANCE This study found that, among adults who underwent complex gastrointestinal cancer surgery, those who received care from high-volume anesthesiologists had a lower risk of adverse postoperative outcomes compared with those who received care from low-volume anesthesiologists. These findings support organizing perioperative care to increase anesthesiologist volume to optimize patient outcomes.