Risk-based Selective Referral for Cancer Surgery A Potential Strategy to Improve Perioperative Outcomes
Risk-based Selective Referral for Cancer Surgery A Potential Strategy to Improve Perioperative Outcomes
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DOI：
10.1097/sla.0b013e3181c1bea2
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发表时间：
2010-04-01
影响因子：
9
通讯作者：
Ko, Clifford Y.
中科院分区：
文献类型：
--
作者：
Bilimoria, Karl Y.;Bentrem, David J.;Ko, Clifford Y.
背景：研究已经证明了许多手术的体积-结果关系，为区域化提供了动力；然而，基于体积的区域化可能不可行或不必要。我们的目标是确定在社区医院接受手术的低风险患者的围手术期死亡率是否与专业中心相当。方法：从国家癌症数据库中，从类似的1430家医院确定了940,718名患者，他们在2003-2005年间接受了15种癌症中的1种手术。根据年龄和合并症将患者按术前风险进行分层。对于每一种癌症，分别使用按高风险组和低风险组分层的回归模型来比较专科中心(国家癌症研究所指定的和/或体量最大的五分之一机构)、其他学术机构(体量较小的非国家癌症研究所)和社区医院的60天死亡率。结果：在15例手术中，13例低风险患者在专科中心和社区医院的围手术期死亡率在统计上相似。对于15种癌症中的9种，高危患者在专科中心的围手术期死亡率显著低于社区医院。不考虑高危人群，专科中心的胰腺切除术和食道切除术的围手术期死亡率显著较低。结论：专科中心和社区医院对除食道癌和胰腺癌外的所有癌症患者的围手术期死亡率是相当的，因此对所有患者基于容量的区域化提出了质疑。相反，只有高危患者可能需要更换医院。如果专门中心的因素能够为高危患者带来更好的结果，并将其转移到其他医院，死亡率就可以降低。
Background: Studies have demonstrated volume-outcome relationships for numerous operations, providing an impetus for regionalization; however, volume-based regionalization may not be feasible or necessary. Our objective was to determine if low-risk patients undergoing surgery at Community Hospitals have perioperative mortality rates comparable with Specialized Centers.Methods: From the National Cancer Data Base, 940,718 patients from similar to 1430 hospitals were identified who underwent resection for 1 of 15 cancers (2003-2005). Patients were stratified by preoperative risk according to age and comorbidities. Separately for each cancer, regression modeling stratified by high-and low-risk groups was used to compare 60-day mortality at Specialized Centers (National Cancer Institute-designated and/or highest-volume quintile institutions), Other Academic Institutions (lower-volume, non-National Cancer Institute), and Community Hospitals.Results: Low-risk patients had statistically similar perioperative mortality rates at Specialized Centers and Community Hospitals for 13 of 15 operations. High-risk patients had significantly lower perioperative mortality rates at Specialized Centers compared with Community Hospitals for 9 of 15 cancers. Regardless of risk group, perioperative mortality rates were significantly lower for pancreatectomy and esophagectomy at Specialized Centers. Risk-based referral compared with volume-based regionalization of most patients would require fewer patients to change to Specialized Centers.Conclusions: Perioperative mortality for low-risk patients was comparable at Specialized Centers and Community Hospitals for all cancers except esophageal and pancreatic, thus questioning volume-based regionalization of all patients. Rather, only high-risk patients may need to change hospitals. Mortality rates could be reduced if factors at Specialized Centers resulting in better outcomes for high-risk patients can be identified and transferred to other hospitals.