Selective referral to high-volume hospitals - Estimating potentially avoidable deaths
Selective referral to high-volume hospitals - Estimating potentially avoidable deaths
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DOI：
10.1001/jama.283.9.1159
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发表时间：
2000-03-01
影响因子：
120.7
通讯作者：
Milstein, A
中科院分区：
文献类型：
--
作者：
Dudley, RA;Johansen, KL;Milstein, A
有证据表明，在某些情况下，高容量医院（HVH）的死亡率低于低容量医院（LVH）。然而，很少有雇主，健康计划，或政府计划试图增加病人的数量转介到HVHs.Objectives之间的医院死亡率的差异HVHS和LVHS的条件下，存在良好的质量数据，并估计有多少死亡可能会避免在加州通过转介到HVHs.Design，Setting，and Patients Literature in MEDLINE，Current Contents，和First-Search Social Abstracts数据库，从1983年1月1日到1998年12月31日，使用关键词医院、结局、死亡率、数量、风险和质量进行检索。确定了评估每种给定条件下死亡率-体积关系的最高质量研究，并用于计算LVH与HVH住院死亡率的比值比（OR）。然后将这些OR应用于1997年加州出院数据库，该数据库由加州全州健康规划和发展办公室维护，以估计潜在可避免的死亡。主要结果测量如果患有死亡率-体积关系的疾病的患者接受HVH与LVH治疗，则潜在可避免的死亡。并应用预定的标准来选择用于每种条件的最佳制品。择期腹主动脉瘤修复术、颈动脉内膜切除术、下肢动脉搭桥手术、冠状动脉搭桥手术、冠状动脉血管成形术、心脏移植、小儿心脏手术、胰腺癌手术、食管癌手术、脑动脉瘤手术和人类免疫缺陷病毒（HIV）/获得性免疫缺陷综合征（AIDS）治疗的HVH组死亡率显著较低。1997年加州的121609例患者中，共有58306例因这些疾病而入住LVH。将计算的OR应用于这些患者人群后，我们估计LVH的602例死亡（95%置信区间，304-830）可归因于其低容量。进行了额外的分析，以考虑到紧急入院和旅行的距离，但损失的连续性护理的一些患者和减少专家的可用性患者留在LVHs的影响无法评估。结论倡议，以方便患者转诊到HVHs有可能降低整体医院死亡率在加州的条件确定。需要进一步研究，以确定选择性转诊的可行程度，并审查这种举措的潜在后果。
Context Evidence exists that high-volume hospitals (HVHs) have lower mortality rates than low-volume hospitals (LVHs) for certain conditions. However, few employers, health plans, or government programs have attempted to increase the number of patients referred to HVHs.Objectives To determine the difference in hospital mortality between HVHs and LVHs for conditions for which good quality data exist and to estimate how many deaths potentially would be avoided in California by referral to HVHs.Design, Setting, and Patients Literature in MEDLINE, Current Contents, and First-Search Social Abstracts databases from January 1, 1983, to December 31, 1998, was searched using the key words hospital, outcome, mortality, volume, risk, and quality. The highest-quality study assessing the mortality-volume relationship for each given condition was identified and used to calculate odds ratios (ORs) for in-hospital mortality for LVHs vs HVHs. These ORs were then applied to the 1997 California database of hospital discharges maintained by the California Office of Statewide Health Planning and Development to estimate potentially avoidable deaths.Main Outcome Measures Deaths that potentially could be avoided if patients with conditions for which a mortality-volume relationship had been treated at an HVH vs LVH.Results The articles identified in the literature search were grouped by condition, and predetermined criteria were applied to choose the best article for each condition. Mortality was significantly lower at HVHs for elective abdominal aortic aneurysm repair, carotid endarterectomy, lower extremity arterial bypass surgery, coronary artery bypass surgery, coronary angioplasty, heart transplantation, pediatric cardiac surgery, pancreatic cancer surgery, esophageal cancer surgery, cerebral aneurysm surgery, and treatment of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). A total of 58 306 of 121 609 patients with these conditions were admitted to LVHs in California in 1997, After applying the calculated ORs to these patient populations, we estimated that 602 deaths (95% confidence interval, 304-830) at LVHs could be attributed to their low volume. Additional analyses were performed to take into account emergent admissions and distance traveled, but the impact of loss of continuity of care for some patients and reduction in the availability of specialists for patients remaining at LVHs could not be assessed.Conclusions Initiatives to facilitate referral of patients to HVHs have the potential to reduce overall hospital mortality in California for the conditions identified. Additional study is needed to determine the extent to which selective referral is feasible and to examine the potential consequences of such initiatives.