The role of provider volume on outcomes after sling surgery for stress urinary incontinence
The role of provider volume on outcomes after sling surgery for stress urinary incontinence
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DOI：
10.1016/j.juro.2006.11.034
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发表时间：
2007-04-01
影响因子：
6.6
通讯作者：
Litwin, Mark S.
中科院分区：
文献类型：
--
作者：
Anger, Jennifer T.;Rodriguez, Larissa V.;Litwin, Mark S.
目的：对各种外科手术的研究记录了提供者数量和结果之间的关系，表明进行大量手术的提供者提供更好的护理质量。我们确定了这种关系在治疗尿失禁的吊带手术中是否成立。材料和方法：我们分析了医疗保险和医疗补助服务中心提供的 1999 年至 2001 年医疗保险公共使用档案，对受益人进行了 5% 的全国随机抽样。对 1999 年 7 月 1 日至 2000 年 12 月 31 日（索引期）期间接受耻骨阴道吊带手术的妇女进行了识别并随访 12 个月。进行的吊带数量根据累积的外科医生体积进行经验分层。主要结局指标包括术后并发症、伴随或延迟的脱垂修复、出口梗阻和重复失禁手术。结果：在指数期内分析的 5% 医疗保险受益人中，进行了 1,356 例吊带手术。由此推断，整个 Medicare 人群中有 27,120 个吊带。高容量提供者（上 24%）在吊带手术时进行的脱垂修复明显多于低容量提供者（40.8% vs 32.4%，p < 0.006）。随后，在索引吊带手术后的第一年内，小容量提供者进行的脱垂修复次数几乎是其两倍（p < 0.0001）。高容量和低容量提供者之间的并发症发生率或重复抗失禁手术没有显着差异。结论：高容量外科医生更有可能在吊带手术时同时进行脱垂手术，而低容量提供者在术后第一年有更高的再手术率来纠正脱垂。这表明大量的医疗服务提供者更有可能在吊带时诊断和处理脱垂，从而无需进行第二次手术。
Purpose: Studies of various surgical procedures have documented a relationship between provider volume and outcomes, suggesting that providers who perform a high volume of procedures provide better quality of care. We ascertained whether this relationship held in sling surgery for urinary incontinence.Materials and Methods: We analyzed the 1999 to 2001 Medicare Public Use Files provided by the Centers for Medicare and Medicaid Services for a 5% national random sample of beneficiaries. Women undergoing pubovaginal sling procedures between July 1, 1999 and December 31, 2000 (the index period) were identified and followed for 12 months. The number of slings performed was stratified empirically by cumulative surgeon volume. Main outcomes measures included postoperative complications, concomitant or delayed prolapse repair, outlet obstruction and repeat incontinence surgery.Results: Among the 5% of Medicare beneficiaries analyzed during the index period 1,356 sling procedures were performed. This extrapolates to 27,120 slings in the entire Medicare population. High volume providers (upper 24th percentile) performed significantly more prolapse repairs at the time of sling surgery than did low volume providers (40.8% vs 32.4%, p < 0.006). Subsequently low volume providers performed almost twice the number of prolapse repairs during the first postoperative year following the index sling procedure (p < 0.0001). There was no significant difference in complication rates or repeat anti-incontinence procedures between high and low volume providers.Conclusions: High volume surgeons were more likely to perform concomitant prolapse surgery at the time of sling surgery, whereas low volume providers had higher reoperation rates to correct prolapse during the first postoperative year. This suggests that high volume providers are more likely to diagnose and manage prolapse at the time of the sling, obviating the need for a second operation.