Hospital volume and 30-day mortality for three common medical conditions.
Hospital volume and 30-day mortality for three common medical conditions.
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DOI：
10.1056/nejmsa0907130
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发表时间：
2010-03-25
期刊：
影响因子：
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通讯作者：
Krumholz HM
中科院分区：
文献类型：
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作者：
Ross JS;Normand SL;Wang Y;Ko DT;Chen J;Drye EE;Keenan PS;Lichtman JH;Bueno H;Schreiner GC;Krumholz HM
对于因急性心肌梗死、心力衰竭或肺炎住院的患者，医院容量与死亡率之间的关系尚不清楚。也不知道是否存在这种关联的卷阈值。我们对2004年至2006年间因急性心肌梗死、心力衰竭或肺炎在美国急性护理医院住院的所有按服务收费受益人的医疗保险行政索赔数据进行了横断面分析。对每种情况使用分层逻辑回归模型，我们估计了与每年医院容量增加100名患者相关的30天内死亡几率的变化。根据患者的危险因素和医院特点对分析结果进行了调整。使用引导程序估计95%置信区间，以确定特定条件的体积阈值，超过该阈值，体积增加与死亡率降低无关。4128家医院有734972例急性心肌梗死住院，4679家医院有1324287例心力衰竭住院，4673家医院有1418252例肺炎住院。医院容量的增加与所有条件下30天死亡率的降低相关（所有比较P<0.001）。对于每种情况，体积和结果之间的关联随着医院体积的增加而减弱。对于急性心肌梗死，一旦年容量达到610例患者（95%可信区间[CI]， 539至679），医院容量增加100例患者不再与死亡几率降低显著相关。心力衰竭的容量阈值为500例（95% CI, 433 - 566），肺炎的容量阈值为210例（95% CI, 142 - 284）。入住容量较大的医院与急性心肌梗死、心力衰竭和肺炎的死亡率降低有关，尽管存在一个容量阈值，超过该阈值后，特定疾病的医院容量增加不再与死亡率降低显著相关。
The association between hospital volume and the death rate for patients who are hospitalized for acute myocardial infarction, heart failure, or pneumonia remains unclear. It is also not known whether a volume threshold for such an association exists. We conducted cross-sectional analyses of data from Medicare administrative claims for all fee-for-service beneficiaries who were hospitalized between 2004 and 2006 in acute care hospitals in the United States for acute myocardial infarction, heart failure, or pneumonia. Using hierarchical logistic-regression models for each condition, we estimated the change in the odds of death within 30 days associated with an increase of 100 patients in the annual hospital volume. Analyses were adjusted for patients’ risk factors and hospital characteristics. Bootstrapping procedures were used to estimate 95% confidence intervals to identify the condition-specific volume thresholds above which an increased volume was not associated with reduced mortality. There were 734,972 hospitalizations for acute myocardial infarction in 4128 hospitals, 1,324,287 for heart failure in 4679 hospitals, and 1,418,252 for pneumonia in 4673 hospitals. An increased hospital volume was associated with reduced 30-day mortality for all conditions (P<0.001 for all comparisons). For each condition, the association between volume and outcome was attenuated as the hospital's volume increased. For acute myocardial infarction, once the annual volume reached 610 patients (95% confidence interval [CI], 539 to 679), an increase in the hospital volume by 100 patients was no longer significantly associated with reduced odds of death. The volume threshold was 500 patients (95% CI, 433 to 566) for heart failure and 210 patients (95% CI, 142 to 284) for pneumonia. Admission to higher-volume hospitals was associated with a reduction in mortality for acute myocardial infarction, heart failure, and pneumonia, although there was a volume threshold above which an increased condition-specific hospital volume was no longer significantly associated with reduced mortality.