PDF(Pubmed)
Abstract：
UNASSIGNED: Minimum volume standards have been advocated as a strategy to improve outcomes for certain surgical procedures. Hospital networks could avoid low-volume surgery by consolidating cases within network hospitals that meet volume standards, thus optimizing outcomes while retaining cases and revenue. The rates of compliance with volume standards among hospital networks and the association of volume standards with outcomes at these hospitals remain unknown.
UNASSIGNED: To quantify low-volume surgery and associated outcomes within hospital networks.
UNASSIGNED: This cross-sectional study used Medicare Provider Analysis and Review data to examine fee-for-service beneficiaries aged 66 to 99 years who underwent 1 of 10 elective surgical procedures (abdominal aortic aneurysm repair, carotid endarterectomy, mitral valve repair, hip or knee replacement, bariatric surgery, or resection for lung, esophageal, pancreatic, or rectal cancers) in a network hospital from 2016 to 2018. Hospital volume for each procedure (calculated with the use of the National Inpatient Sample) was compared with yearly hospital volume standards for that procedure recommended by The Leapfrog Group. Networks were then categorized into 4 groups according to whether or not that hospital or another hospital in the network met low-volume standards for that procedure. Data were analyzed from February to June 2023.
UNASSIGNED: Receipt of surgery in a low-volume hospital within a network.
UNASSIGNED: Primary outcomes were postoperative complications, 30-day readmission, and 30-day mortality, stratified by the volume status of the hospital and network type. The secondary outcome was the availability of a different high-volume hospital within the same network or outside the network and its proximity to the patient (based on hospital referral region and zip code).
UNASSIGNED: In all, data were analyzed for 950 079 Medicare fee-for-service beneficiaries (mean [SD] age, 74.4 [6.5] years; 621 138 females [59.2%] and 427 931 males [40.8%]) who underwent 1 049 069 procedures at 2469 hospitals within 382 networks. Of these networks, 380 (99.5%) had at least 1 low-volume hospital performing the elective procedure of interest. In 35 137 of 44 011 procedures (79.8%) that were performed at low-volume hospitals, there was a hospital that met volume standards within the same network and hospital referral region located a median (IQR) distance of 29 (12-60) miles from the patient\'s home. Across hospital networks, there was 43-fold variation in rates of low-volume surgery among the procedures studied (from 1.5% of carotid endarterectomies to 65.0% of esophagectomies). In adjusted analyses, postoperative outcomes were inferior at low-volume hospitals compared with hospitals meeting volume standards, with a 30-day mortality of 8.1% at low-volume hospitals vs 5.5% at hospitals that met volume standards (adjusted odds ratio, 0.67 [95% CI, 0.61-0.73]; P < .001).
UNASSIGNED: Findings of this study suggest that most US hospital networks had hospitals performing low-volume surgery that is associated with inferior surgical outcomes despite availability of a different in-network hospital that met volume standards within a median of 29 miles for the vast majority of patients. Strategies are needed to help patients access high-quality care within their networks, including avoidance of elective surgery at low-volume hospitals. Avoidance of low-volume surgery could be considered a process measure that reflects attention to quality within hospital networks.
UNASSIGNED: To quantify low-volume surgery and associated outcomes within hospital networks.
UNASSIGNED: This cross-sectional study used Medicare Provider Analysis and Review data to examine fee-for-service beneficiaries aged 66 to 99 years who underwent 1 of 10 elective surgical procedures (abdominal aortic aneurysm repair, carotid endarterectomy, mitral valve repair, hip or knee replacement, bariatric surgery, or resection for lung, esophageal, pancreatic, or rectal cancers) in a network hospital from 2016 to 2018. Hospital volume for each procedure (calculated with the use of the National Inpatient Sample) was compared with yearly hospital volume standards for that procedure recommended by The Leapfrog Group. Networks were then categorized into 4 groups according to whether or not that hospital or another hospital in the network met low-volume standards for that procedure. Data were analyzed from February to June 2023.
UNASSIGNED: Receipt of surgery in a low-volume hospital within a network.
UNASSIGNED: Primary outcomes were postoperative complications, 30-day readmission, and 30-day mortality, stratified by the volume status of the hospital and network type. The secondary outcome was the availability of a different high-volume hospital within the same network or outside the network and its proximity to the patient (based on hospital referral region and zip code).
UNASSIGNED: In all, data were analyzed for 950 079 Medicare fee-for-service beneficiaries (mean [SD] age, 74.4 [6.5] years; 621 138 females [59.2%] and 427 931 males [40.8%]) who underwent 1 049 069 procedures at 2469 hospitals within 382 networks. Of these networks, 380 (99.5%) had at least 1 low-volume hospital performing the elective procedure of interest. In 35 137 of 44 011 procedures (79.8%) that were performed at low-volume hospitals, there was a hospital that met volume standards within the same network and hospital referral region located a median (IQR) distance of 29 (12-60) miles from the patient\'s home. Across hospital networks, there was 43-fold variation in rates of low-volume surgery among the procedures studied (from 1.5% of carotid endarterectomies to 65.0% of esophagectomies). In adjusted analyses, postoperative outcomes were inferior at low-volume hospitals compared with hospitals meeting volume standards, with a 30-day mortality of 8.1% at low-volume hospitals vs 5.5% at hospitals that met volume standards (adjusted odds ratio, 0.67 [95% CI, 0.61-0.73]; P < .001).
UNASSIGNED: Findings of this study suggest that most US hospital networks had hospitals performing low-volume surgery that is associated with inferior surgical outcomes despite availability of a different in-network hospital that met volume standards within a median of 29 miles for the vast majority of patients. Strategies are needed to help patients access high-quality care within their networks, including avoidance of elective surgery at low-volume hospitals. Avoidance of low-volume surgery could be considered a process measure that reflects attention to quality within hospital networks.
摘要：
■已提倡将最小体积标准作为改善某些外科手术结果的策略。医院网络可以通过在网络医院内整合符合容量标准的病例来避免小容量手术，从而优化结果，同时保留案件和收入。医院网络中对容量标准的遵守率以及这些医院的容量标准与结果的关联仍然未知。
■量化医院网络中的小容量手术和相关结果。
■这项横断面研究使用Medicare提供者分析和审查数据来检查66至99岁的按服务付费受益人，他们接受了10项选择性外科手术中的1项（腹主动脉瘤修复术，颈动脉内膜切除术,二尖瓣修复术,髋关节或膝关节置换术，减肥手术,或者肺切除术，食道,胰腺,或直肠癌)在2016年至2018年的网络医院。将每个程序的医院体积（使用国家住院患者样本计算）与LeapfrogGroup推荐的该程序的年度医院体积标准进行比较。然后，根据该医院或网络中的另一家医院是否符合该程序的低容量标准，将网络分为4组。对2023年2月至6月的数据进行了分析。
■在网络内的小批量医院接受手术。
■主要结果是术后并发症，重新接纳30天,和30天死亡率，按医院的容量状态和网络类型进行分层。次要结果是同一网络内或网络外的不同高容量医院的可用性及其与患者的距离（基于医院转诊地区和邮政编码）。
■总之，分析了950079名医疗保险按服务付费受益人的数据(平均[SD]年龄，74.4[6.5]岁；621138名女性[59.2％]和427931名男性[40.8％]），在382个网络中的2469家医院接受了1049069次手术。在这些网络中,380家（99.5％）的医院至少有一家低容量医院进行了感兴趣的选择性手术。在低容量医院进行的44011例手术中，有35137例(79.8%)，在同一网络和医院转诊区域内,有一家符合容量标准的医院距离患者家的中位距离(IQR)为29(12-60)英里.在整个医院网络中，在所研究的手术中,小容量手术的比例差异为43倍(从1.5%的颈动脉内膜切除术到65.0%的食管切除术).在调整后的分析中，与符合容量标准的医院相比，低容量医院的术后结局较差，低容量医院的30天死亡率为8.1%，符合容量标准的医院为5.5%(调整后的赔率比，0.67[95%CI，0.61-0.73]；P<.001）。
这项研究的结果表明，大多数美国医院网络的医院都进行了低容量手术，这与较差的手术结果有关，尽管有不同的网络内医院，其符合容量标准，绝大多数患者的中位数为29英里。需要策略来帮助患者在其网络中获得高质量的护理，包括避免在低容量医院进行择期手术。避免小批量手术可以被认为是一种过程措施，反映了对医院网络质量的关注。
■量化医院网络中的小容量手术和相关结果。
■这项横断面研究使用Medicare提供者分析和审查数据来检查66至99岁的按服务付费受益人，他们接受了10项选择性外科手术中的1项（腹主动脉瘤修复术，颈动脉内膜切除术,二尖瓣修复术,髋关节或膝关节置换术，减肥手术,或者肺切除术，食道,胰腺,或直肠癌)在2016年至2018年的网络医院。将每个程序的医院体积（使用国家住院患者样本计算）与LeapfrogGroup推荐的该程序的年度医院体积标准进行比较。然后，根据该医院或网络中的另一家医院是否符合该程序的低容量标准，将网络分为4组。对2023年2月至6月的数据进行了分析。
■在网络内的小批量医院接受手术。
■主要结果是术后并发症，重新接纳30天,和30天死亡率，按医院的容量状态和网络类型进行分层。次要结果是同一网络内或网络外的不同高容量医院的可用性及其与患者的距离（基于医院转诊地区和邮政编码）。
■总之，分析了950079名医疗保险按服务付费受益人的数据(平均[SD]年龄，74.4[6.5]岁；621138名女性[59.2％]和427931名男性[40.8％]），在382个网络中的2469家医院接受了1049069次手术。在这些网络中,380家（99.5％）的医院至少有一家低容量医院进行了感兴趣的选择性手术。在低容量医院进行的44011例手术中，有35137例(79.8%)，在同一网络和医院转诊区域内,有一家符合容量标准的医院距离患者家的中位距离(IQR)为29(12-60)英里.在整个医院网络中，在所研究的手术中,小容量手术的比例差异为43倍(从1.5%的颈动脉内膜切除术到65.0%的食管切除术).在调整后的分析中，与符合容量标准的医院相比，低容量医院的术后结局较差，低容量医院的30天死亡率为8.1%，符合容量标准的医院为5.5%(调整后的赔率比，0.67[95%CI，0.61-0.73]；P<.001）。
这项研究的结果表明，大多数美国医院网络的医院都进行了低容量手术，这与较差的手术结果有关，尽管有不同的网络内医院，其符合容量标准，绝大多数患者的中位数为29英里。需要策略来帮助患者在其网络中获得高质量的护理，包括避免在低容量医院进行择期手术。避免小批量手术可以被认为是一种过程措施，反映了对医院网络质量的关注。
