Is the hospital volume-mortality relationship in coronary artery bypass surgery the same for low-risk versus high-risk patients?
Is the hospital volume-mortality relationship in coronary artery bypass surgery the same for low-risk versus high-risk patients?
复制标题
对于低风险和高风险患者，冠状动脉搭桥手术的医院数量与死亡率关系是否相同？
DOI：
10.1016/s0003-4975(03)00114-0
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发表时间：
2003
期刊：
影响因子：
--
通讯作者：
Osler,TurnerM
中科院分区：
文献类型：
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作者：
Glance,LaurentG;Dick,AndrewW;Mukamel,DanaB;Osler,TurnerM
背景：有证据支持冠状动脉搭桥术（CABG）术后死亡率与手术量呈负相关。目前尚不清楚是否所有患者都能从在大容量中心进行冠脉搭桥手术中获益。本研究的目的是确定CABG手术的容量-结果相关性是否会因患者风险而改变。方法回顾性队列分析使用心脏手术报告系统数据库中的数据，对1996年在纽约州接受冠状动脉搭桥手术的所有患者（20,078例）进行分析。主要结局指标是调整疾病严重程度后，住院死亡率作为手术量的函数。采用Logistic回归模型探讨患者风险与手术量之间的相互作用。结果手术量与患者风险之间存在显著交互作用（p = 0.01）。最终模型具有良好的判别性（C统计量= 0.818）和拟合优度（Hosmer-Lemeshow统计量= 6.02;p = 0.645）。在高容量中心，极低（<0.5%）和低风险（0.5% - 2.0%）患者的冠状动脉搭桥死亡率比高（5.0%-10.0%）和极高风险（>10%）患者的死亡率降低更大。在高危患者中（死亡风险为25%），高危患者在高容量中心的预后较好。结论：对于绝大多数患者来说，在大容量中心而不是小容量中心进行CABG手术，低风险患者的获益明显高于高风险患者。在大容量中心而不是小容量中心进行CABG手术，低风险患者比高风险患者获益明显更多。然而，在将这些发现推广到其他州之前，应该使用其他地区基于人群的临床数据库重复这项研究。
BACKGROUNDThere is evidence to support the existence of an inverse relation between mortality after coronary artery bypass graft (CABG) surgery and procedure volume. It is unclear whether all patients benefit equally from having CABG surgery performed at high-volume centers. The objective of this study was to determine whether the volume-outcome association for CABG surgery is modified by patient risk.METHODSThis retrospective cohort analysis was conducted using data from the Cardiac Surgery Reporting System database on all patients (20,078) undergoing CABG surgery in New York State who were discharged in 1996. The main outcome measure was in-hospital mortality as a function of procedure volume after adjusting for severity of disease. Logistic regression modeling was used to explore the interaction between patient risk and procedure volume.RESULTSThere is a significant interaction between procedure volume and patient risk (p = 0.01). The final model exhibits excellent discrimination (C statistic = 0.818) and goodness-of-fit (Hosmer-Lemeshow statistic = 6.02; p = 0.645). Very low (<0.5%) and low-risk (0.5%–2.0%) patients exhibit a greater reduction in CABG mortality than high (5.0%–10.0%) and very high risk (>10%) patients at high-volume centers relative to low-volume centers. Among the highest risk patients (>25% risk of mortality), higher risk patients have better outcomes at higher volume centers.CONCLUSIONSFor the vast majority of patients, low-risk patients benefit significantly more than high-risk patients from undergoing CABG surgery at high-volume centers instead of at low-volume centers. Low-risk patients benefit significantly more than high-risk patients from undergoing CABG surgery at high-volume centers instead of at low-volume centers. However, before generalizing these findings to other states, this study should be repeated using other regional population-based clinical databases.