若醫院的手術經驗少 髖骨、膝關節置換術風險較高


  【24drs.com】根據線上發表於6月7日關節炎&風濕病(Arthritis & Rheumatism)期刊的一篇大型資料庫研究結果,醫院手術經驗少與全髖關節或全膝關節置換術(THA/TKA))術後靜脈血栓及死亡率風險較高有關。
  
  第一作者、阿拉巴馬大學的Jasvinder A. Singh在新聞稿中表示,美國選擇進行關節置換術的患者日增,對這類關節置換手術而言,暸解相關的術前與術後影響及併發症甚為重要,可能的心臟併發症、血栓或感染都會增加病患的發病率及死亡率風險,會消耗更多照護資源和費用。
  
  研究目標是評估院內手術經驗和初次選擇進行THA/TKA之手術結果的關聯,研究對象是所有在賓州初次選擇進行THA/TKA的病患,資料來源是「Pennsylvania Health Care Cost Containment Council」資料庫;根據每年的THA/TKA手術經驗將醫院分為四類:25件以下、26-100件、101-200件、200件以上,每年手術超過200件的醫院被視為經驗多的醫院。
  
  研究使用邏輯回歸模式確認30天時的併發症、30天與1年時的死亡率,校正變項包括年紀、性別、種族、保險類型、醫院區域、3M所有病人診斷相關改良分組之死亡率風險分數、醫院的教學狀況、病床數,病患的平均年紀為69歲,THA組有10,187人,42.8%是男性,TKA組有19,418人,35%是男性。
  
  採用多變項校正勝算比(ORs) 分析,比較初次選擇進行THA經驗少的醫院(每年件數≦25,26 – 100與101 – 200者)與經驗多的醫院,前者的靜脈栓塞風險較高:分別達2.0 (95%信心區間[CI]為0.2 - 16.0)、3.4 (95% CI,1.4 - 8.0)與1.1 (95% CI,0.3 - 3.7)(P = .02)。1年死亡率的OR也較高,分別是2.1(95% CI,1.2 - 3.6)、2.0 (95% CI,1.4 - 2.9)與1.0 (95% CI,0.7 - 1.5)(P < .01)。
  
  對於初次選擇TKA且至少65歲的病患,經驗少的醫院(每年件數≦25, 26 – 100與101 – 200者)與經驗多的醫院相比較, 1年死亡率的OR分別是0.6(95% CI,0.2 - 2.1)、1.6 (95% CI,1.0 - 2.4)與0.9 (95% CI,0.6 - 1.3) (P = .02)。
  
  研究作者結論表示,經驗少的醫院與初次選擇進行THA/TKA之後的靜脈栓塞及死亡率風險較高有關,可能有受到一些未檢測的變項影響,應針對可修改的系統因素/過程來降低併發症。
  
  研究限制包括,使用大型的住院資料庫,可能在紀錄上有不一致之處,缺乏某些關鍵變項的資訊,可能還有其他未檢測的因素,各種結果的案例數有限。
  
  Singh醫師表示,需要後續研究探討經驗少醫院手術結果不佳的原因是否可修改,以及哪些介入方式可降低這些機構內的病患併發症。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6542&x_classno=0&x_chkdelpoint=Y
  

Hip, Knee Arthroplasty Riskier When Surgical Volume Is Low

By Laurie Barclay, MD
Medscape Medical News

June 8, 2011 — A low hospital surgery volume is associated with a higher risk for venous thromboembolism and mortality after primary elective total hip or total knee arthroplasty (THA/TKA), according to the results of a large database study reported online June 7 in Arthritis & Rheumatism.

"With the large number of elective arthroplasty in the U.S., it is important to understand the impact of peri- and post-operative medical complications on the success of joint replacement surgery," said lead author Jasvinder A. Singh, MBBS, MPH, from the University of Alabama at Birmingham, in a news release. "Possible cardiac complications, blood clots, or infections increase patient morbidity and mortality risk, which can lead to higher health care utilization and costs."

The goal of the study was to evaluate the association between hospital procedure volume and surgical outcomes of primary elective THA/TKA. The investigators identified all patients who underwent primary elective THA/TKA in Pennsylvania, using the Pennsylvania Health Care Cost Containment Council database. Four categories of hospitals were identified, based on annual THA/TKA procedure volume of 25 or less, 26 to 100, 101 to 200, and more than 200 procedures. High-volume hospitals were defined as those performing more than 200 procedures per year.

The investigators determined complications at 30 days and mortality at 30 days and at 1 year using logistic regression models, with adjustment for age, sex, race, insurance type, hospital region, 3M All Patient Refined-Diagnosis Related Group Risk of Mortality score, hospital teaching status, and bed count. Mean age was 69 years in the THA cohort (n = 10,187; 42.8% men) and in the TKA cohort (n = 19,418; 35% men).

For elective primary THA at low-volume hospitals (? 25, 26 - 100, and 101 - 200 procedures annually) vs high-volume hospitals, multivariable-adjusted odds ratios (ORs) were higher for venous thromboembolism: 2.0 (95% confidence interval [CI], 0.2 - 16.0), 3.4 (95% CI, 1.4 - 8.0), and 1.1 (95% CI, 0.3 - 3.7), respectively (P = .02). ORs were also higher for 1-year mortality: 2.1 (95% CI, 1.2 - 3.6), 2.0 (95% CI, 1.4 - 2.9), and 1.0 (95% CI, 0.7 - 1.5), respectively (P < .01).

For elective primary TKA in patients at least 65 years old, those who had the procedure at low-volume hospitals (? 25, 26 - 100, and 101 - 200 annually) vs high-volume hospitals had ORs for 1-year mortality of 0.6 (95% CI, 0.2 - 2.1), 1.6 (95% CI, 1.0 - 2.4), and 0.9 (95% CI, 0.6 - 1.3), respectively (P = .02).

"A low hospital surgery volume was associated with higher risk of venous thromboembolism and mortality after primary elective THA/TKA," the study authors conclude. "Confounding due to unmeasured variables is possible. Modifiable system-based factors/processes should be targeted to reduce complications."

Limitations of this study include use of a large administrative database with potential inconsistencies in documentation and no information on certain key variables, possible residual confounding because of unmeasured variables, and low number of events for several outcomes.

"Further studies are needed to investigate whether the underlying reasons for poor surgical outcomes at low-volume hospitals are modifiable and which interventions may reduce complications for patients at these facilities," Dr. Singh said.

The National Institutes of Health supported this study, which used the resources and facilities of the VA Medical Centers at Birmingham, Pittsburgh, and Philadelphia. Dr. Singh has received speaker honoraria from Abbott; research and travel grants from Allergan, Takeda, Savient, Wyeth, and Amgen; and consultant fees from Savient, Novartis, and URL Pharmaceuticals. Another study author (Kent Kwoh, MD) has received grants from AstraZeneca and the Beverage Institute. The other study authors have disclosed no relevant financial relationships.

Arthritis Rheum. Published online June 7, 2011.

    
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