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Abstract：
BACKGROUND: Centralization of hepatopancreatobiliary procedures to more experienced centers has been recommended but remains controversial. Hospital volume and risk-stratified mortality rates (RSMR) are metrics for interhospital comparison. We compared facility operative volume with facility RSMR as a proxy for hospital quality.
METHODS: Patients who underwent surgery for liver (LC), biliary tract (BTC), and pancreatic (PDAC) cancer were identified in the National Cancer Database (2004-2018). Hierarchical logistic regression was used to create facility-specific models for RSMR. Volume (high versus low) was determined by quintile. Performance (high versus low) was determined by RSMR tercile. Primary outcomes included median facility RSMR and RSMR distributions. Volume- and RSMR-based redistribution was simulated and compared for reductions in 90-day mortality.
RESULTS: A total of 106,217 patients treated at 1282 facilities were included; 17,695 had LC, 23,075 had BTC, and 65,447 had PDAC. High-volume centers (HVC) had lower RSMR compared with medium-volume centers and low-volume centers for LC, BTC, and PDAC (all p < 0.001). High-performance centers (HPC) had lower RSMR compared with medium-performance centers and low-performance centers for LC, BTC, and PDAC (all p < 0.001). Volume-based redistribution required 16.0 patients for LC, 11.2 for BTC, and 14.9 for PDAC reassigned to 15, 22, and 20 centers, respectively, per life saved within each US census region. RSMR-based redistribution required 4.7 patients for LC, 4.2 for BTC, and 4.9 for PDAC reassigned to 316, 403, and 418 centers, respectively, per life saved within each US census region.
CONCLUSIONS: HVC and HPC have the lowest overall and risk-standardized 90-day mortality after oncologic hepatopancreatobiliary procedures, but RSMR may outperform volume as a measure of hospital quality.
METHODS: Patients who underwent surgery for liver (LC), biliary tract (BTC), and pancreatic (PDAC) cancer were identified in the National Cancer Database (2004-2018). Hierarchical logistic regression was used to create facility-specific models for RSMR. Volume (high versus low) was determined by quintile. Performance (high versus low) was determined by RSMR tercile. Primary outcomes included median facility RSMR and RSMR distributions. Volume- and RSMR-based redistribution was simulated and compared for reductions in 90-day mortality.
RESULTS: A total of 106,217 patients treated at 1282 facilities were included; 17,695 had LC, 23,075 had BTC, and 65,447 had PDAC. High-volume centers (HVC) had lower RSMR compared with medium-volume centers and low-volume centers for LC, BTC, and PDAC (all p < 0.001). High-performance centers (HPC) had lower RSMR compared with medium-performance centers and low-performance centers for LC, BTC, and PDAC (all p < 0.001). Volume-based redistribution required 16.0 patients for LC, 11.2 for BTC, and 14.9 for PDAC reassigned to 15, 22, and 20 centers, respectively, per life saved within each US census region. RSMR-based redistribution required 4.7 patients for LC, 4.2 for BTC, and 4.9 for PDAC reassigned to 316, 403, and 418 centers, respectively, per life saved within each US census region.
CONCLUSIONS: HVC and HPC have the lowest overall and risk-standardized 90-day mortality after oncologic hepatopancreatobiliary procedures, but RSMR may outperform volume as a measure of hospital quality.
摘要：
背景：已建议将肝胰胆管手术集中到更有经验的中心，但仍存在争议。医院数量和危险分层死亡率（RSMR）是医院间比较的指标。我们比较了设施手术量和设施RSMR作为医院质量的代表。
方法：接受肝脏手术（LC）的患者，胆道（BTC），和胰腺癌（PDAC）在国家癌症数据库（2004-2018）中确定。分层逻辑回归用于创建RSMR的设施特定模型。体积(高与低)由五分位数确定。性能(高与低)由RSMRtercile确定。主要结果包括中位设施RSMR和RSMR分布。模拟了基于体积和RSMR的再分布，并比较了90天死亡率的降低。
结果：共纳入了在1282个机构接受治疗的106,217名患者；17,695名患者患有LC，23,075有BTC，65,447人患有PDAC。与LC的中等体积中心和低体积中心相比，高体积中心（HVC）的RSMR较低，BTC,和PDAC（所有p<0.001）。与LC的中等性能中心和低性能中心相比，高性能中心(HPC)的RSMR较低，BTC,和PDAC（所有p<0.001）。基于体积的再分配需要16.0名患者进行LC，11.2对于BTC，PDAC重新分配给15、22和20个中心的14.9个，分别,在每个美国人口普查区域内保存的每条生命。基于RSMR的再分配需要4.7名患者进行LC，4.2对于BTC，和4.9对于重新分配给316、403和418中心的PDAC，分别,在每个美国人口普查区域内保存的每条生命。
结论：HVC和HPC在肝胰胆管肿瘤手术后的90天总体死亡率和风险标准化死亡率最低，但作为衡量医院质量的指标，RSMR可能优于容量。
方法：接受肝脏手术（LC）的患者，胆道（BTC），和胰腺癌（PDAC）在国家癌症数据库（2004-2018）中确定。分层逻辑回归用于创建RSMR的设施特定模型。体积(高与低)由五分位数确定。性能(高与低)由RSMRtercile确定。主要结果包括中位设施RSMR和RSMR分布。模拟了基于体积和RSMR的再分布，并比较了90天死亡率的降低。
结果：共纳入了在1282个机构接受治疗的106,217名患者；17,695名患者患有LC，23,075有BTC，65,447人患有PDAC。与LC的中等体积中心和低体积中心相比，高体积中心（HVC）的RSMR较低，BTC,和PDAC（所有p<0.001）。与LC的中等性能中心和低性能中心相比，高性能中心(HPC)的RSMR较低，BTC,和PDAC（所有p<0.001）。基于体积的再分配需要16.0名患者进行LC，11.2对于BTC，PDAC重新分配给15、22和20个中心的14.9个，分别,在每个美国人口普查区域内保存的每条生命。基于RSMR的再分配需要4.7名患者进行LC，4.2对于BTC，和4.9对于重新分配给316、403和418中心的PDAC，分别,在每个美国人口普查区域内保存的每条生命。
结论：HVC和HPC在肝胰胆管肿瘤手术后的90天总体死亡率和风险标准化死亡率最低，但作为衡量医院质量的指标，RSMR可能优于容量。
