The Effects of Trauma Center Care, Admission Volume, and Surgical Volume on Paralysis After Traumatic Spinal Cord Injury
The Effects of Trauma Center Care, Admission Volume, and Surgical Volume on Paralysis After Traumatic Spinal Cord Injury
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DOI：
10.1097/sla.0b013e31818a1505
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发表时间：
2009-01-01
影响因子：
9
通讯作者：
Angus, Derek C.
中科院分区：
文献类型：
--
作者：
Macias, Carlos Aitor;Rosengart, Matthew R.;Angus, Derek C.
目的：评价美国外科医师学会（American College of Surgeons， ACS）指南的依从性，以及创伤中心指定、医院外伤性脊髓损伤（traumatic spinal cord injury， TSCI）病例量或脊柱手术量是否与瘫痪有关。我们先验地假设，与非创伤中心护理相比，创伤中心护理与出院时瘫痪的减少有关。摘要背景数据：在美国每年大约有11000人发生TSCI。ACS建议所有TSCI患者被送往一级或二级创伤中心。方法：对美国7个州（佛罗里达州、马萨诸塞州、新泽西州、纽约州、德克萨斯州、弗吉尼亚州、华盛顿州）2001年出院档案中按ICD-9-CM标准诊断为TSCI的4121例患者进行研究，这些患者分别在100家创伤中心和601家非创伤中心接受治疗。我们进行了多变量分析，包括倾向得分五分位数方法，调整了不同医院和州的病例组合和聚类差异。我们还研究了3125名患者，使用1996年、2001年和2006年扩大修改的医疗保险提供者分析和审查记录，以评估创伤中心指定的瘫痪时间趋势。结果：死亡率为7.5%。16.3%的患者瘫痪出院。只有57.9% （n = 2378）在指定的创伤中心接受治疗。创伤中心的入院病例量高出16倍（20.7比1.3,P < 0.001），手术量高出30倍（9.6比0.3,P < 0.001）。在多变量倾向分析中，创伤中心瘫痪的发生率显著降低（校正优势比0.67；95%可信区间0.53-0.85;P = 0.001）。更高的手术量，而不是更高的入院量，与更低的瘫痪风险相关。事实上，在非创伤中心，较高的入院病例量与较差的结果相关。死亡率无显著差异。结论：创伤中心护理与TSCI后瘫痪的减少有关，可能是因为更多地使用脊柱手术。将所有这类患者分诊到创伤中心的国家指导方针的执行率略高于一半。
Objective: To evaluate compliance with American College of Surgeons (ACS) guidelines and whether trauma center designation, hospital traumatic spinal cord injury (TSCI) case volume or spinal surgery volume is associated with paralysis. We hypothesized a priori that trauma center care, by contrast to nontrauma center care, is associated with reduced paralysis at discharge.Summary Background Data: Approximately 11,000 persons incur a TSCI in the United States annually. The ACS recommends all TSCI patients be taken to a level I or II trauma center.Methods: We studied 4121 patients diagnosed with TSCI by ICD-9-CM criteria in the 2001 hospital discharge files of 7 states (Florida, Massachusetts, New Jersey, New York, Texas, Virginia, Washington), who were treated in 100 trauma centers and 601 nontrauma centers. We performed multivariate analyses, including a propensity score quintile approach, adjusting for differences in case mix and clustering by hospital and by state. We also studied 3125 patients using the expanded modified Medicare Provider Analysis and Review records for the years 1996, 2001, and 2006 to assess temporal trends in paralysis by trauma center designation.Results: Mortality was 7.5%. and 16.3% were discharged with paralysis. Only 57.9% (n = 2378) received care at a designated trauma center. Trauma centers had a 16-fold higher admission caseload (20.7 vs. 1.3; P < 0.001) and 30-fold higher surgical volume (9.6 vs. 0.3; P < 0.001). In the multivariate propensity analysis, paralysis was significantly lower at trauma centers (adjusted odds ratio 0.67; 95% confidence interval, 0.53-0.85; P = 0.001). Higher surgical volume, not higher admission volume, was associated with lower risk of paralysis. Indeed, at nontrauma centers, higher admission caseload was associated with worse outcome. There was no significant difference in mortality.Conclusions: Trauma center care is associated with reduced paralysis after TSCI, possibly because of greater use of spinal surgery. National guidelines to triage all such patients to trauma centers are followed little more than half the time.