Abstract：
BACKGROUND: Limited evidence exists on the influence of hospital procedure volume, socioeconomic status, and comorbidities on surgical abortion outcomes.
OBJECTIVE: Our study aimed to assess the association between hospital procedure volume, individual and neighborhood deprivation, comorbidities, and abortion-related adverse events.
METHODS: A nationwide population-based cohort study of all women hospitalized for surgical abortion was conducted from January 1, 2018, to December 31, 2019 in France. Annual hospital procedure volume was categorized into four levels based on spline function visualization: very low (<80), low ([80-300[), high ([300-650[), and very high-volume (≥650) centers. The primary outcome was the occurrence of at least one surgical-related adverse event, including hemorrhage, retained products of conception, genital tract and pelvic infection, transfusion, fistulas and neighboring lesions, local hematoma, failure of abortion, admission to an intensive care unit or death. These events were monitored during the index stay and during a subsequent hospitalization up to 90 days. The secondary outcome encompassed general adverse events not directly linked to surgery.
RESULTS: Of the 112,842 hospital stays, 4,951 (4.39%) had surgical-related adverse events and 256 (0.23%) had general adverse events. The multivariate analysis showed a volume-outcome relationship, with lower rates of surgical-related adverse events in very high-volume (2.25%, aOR=0.34, 95%CI [0.29-0.39], p<0.001), high-volume (4.24%, aOR=0.61, 95%CI [0.55-0.69], p<0.001), and low-volume (4.69%, aOR=0.81, 95%CI [0.75-0.88], p<0.001) when compared to very low-volume centers (6.65%). Individual socioeconomic status (aOR=1.69, 95%CI [1.47-1.94], p<0.001), neighborhood deprivation (aOR=1.31, 95% CI [1.22-1.39], p<0.001), and comorbidities (aOR=1.79, 95%CI [1.35-2.38], p<0.001) were associated with surgical-related adverse events. Conversely, the multivariate analysis of general adverse events did not reveal any volume-outcome relationship.
CONCLUSIONS: The presence of a volume-outcome relationship underscores the need for enhanced safety standards in low-volume centers to ensure equity in women\'s safety during surgical abortions. However, our findings also highlight the complexity of this safety concern which involves multiple other factors including socioeconomic status and comorbidities that policymakers must consider.
OBJECTIVE: Our study aimed to assess the association between hospital procedure volume, individual and neighborhood deprivation, comorbidities, and abortion-related adverse events.
METHODS: A nationwide population-based cohort study of all women hospitalized for surgical abortion was conducted from January 1, 2018, to December 31, 2019 in France. Annual hospital procedure volume was categorized into four levels based on spline function visualization: very low (<80), low ([80-300[), high ([300-650[), and very high-volume (≥650) centers. The primary outcome was the occurrence of at least one surgical-related adverse event, including hemorrhage, retained products of conception, genital tract and pelvic infection, transfusion, fistulas and neighboring lesions, local hematoma, failure of abortion, admission to an intensive care unit or death. These events were monitored during the index stay and during a subsequent hospitalization up to 90 days. The secondary outcome encompassed general adverse events not directly linked to surgery.
RESULTS: Of the 112,842 hospital stays, 4,951 (4.39%) had surgical-related adverse events and 256 (0.23%) had general adverse events. The multivariate analysis showed a volume-outcome relationship, with lower rates of surgical-related adverse events in very high-volume (2.25%, aOR=0.34, 95%CI [0.29-0.39], p<0.001), high-volume (4.24%, aOR=0.61, 95%CI [0.55-0.69], p<0.001), and low-volume (4.69%, aOR=0.81, 95%CI [0.75-0.88], p<0.001) when compared to very low-volume centers (6.65%). Individual socioeconomic status (aOR=1.69, 95%CI [1.47-1.94], p<0.001), neighborhood deprivation (aOR=1.31, 95% CI [1.22-1.39], p<0.001), and comorbidities (aOR=1.79, 95%CI [1.35-2.38], p<0.001) were associated with surgical-related adverse events. Conversely, the multivariate analysis of general adverse events did not reveal any volume-outcome relationship.
CONCLUSIONS: The presence of a volume-outcome relationship underscores the need for enhanced safety standards in low-volume centers to ensure equity in women\'s safety during surgical abortions. However, our findings also highlight the complexity of this safety concern which involves multiple other factors including socioeconomic status and comorbidities that policymakers must consider.
摘要：
背景：关于医院手术量影响的证据有限，社会经济地位,和合并症对手术流产结果的影响。
目的：我们的研究旨在评估医院手术量之间的关联，个人和邻里剥夺，合并症,与流产相关的不良事件。
方法：于2018年1月1日至2019年12月31日在法国对所有因手术流产住院的妇女进行了一项基于人群的队列研究。根据样条函数可视化将医院年度手术量分为四个级别：非常低（<80），低（[80-300[），高（[300-650[），和非常高容量（≥650）中心。主要结果是发生至少一个手术相关的不良事件。包括出血,保留的受孕产品，生殖道和盆腔感染，输血,瘘管和邻近的病变,局部血肿,流产失败,入住重症监护病房或死亡。在索引住院期间和随后的住院期间监测这些事件长达90天。次要结果包括与手术无直接关系的一般不良事件。
结果：在112,842次住院中，4,951（4.39％）发生手术相关不良事件，256（0.23％）发生一般不良事件。多变量分析显示体积与结果的关系，在非常大量的情况下，手术相关的不良事件发生率较低(2.25%，OR=0.34,95CI[0.29-0.39],p<0.001)，高容量（4.24%，OR=0.61，95CI[0.55-0.69]，p<0.001)，和低容量(4.69%，OR=0.81,95CI[0.75-0.88],当与非常低体积的中心(6.65%)相比时,p<0.001)。个人社会经济地位(aOR=1.69，95CI[1.47-1.94]，p<0.001)，邻里剥夺(aOR=1.31，95%CI[1.22-1.39]，p<0.001)，和合并症（aOR=1.79，95CI[1.35-2.38]，p<0.001）与手术相关的不良事件有关。相反，一般不良事件的多变量分析未显示任何容量与结局的关系.
结论：容量-结果关系的存在强调了在低容量中心需要加强安全标准，以确保手术流产期间妇女安全的公平性。然而,我们的研究结果还强调了这种安全问题的复杂性,它涉及多种其他因素,包括社会经济地位和决策者必须考虑的合并症.
目的：我们的研究旨在评估医院手术量之间的关联，个人和邻里剥夺，合并症,与流产相关的不良事件。
方法：于2018年1月1日至2019年12月31日在法国对所有因手术流产住院的妇女进行了一项基于人群的队列研究。根据样条函数可视化将医院年度手术量分为四个级别：非常低（<80），低（[80-300[），高（[300-650[），和非常高容量（≥650）中心。主要结果是发生至少一个手术相关的不良事件。包括出血,保留的受孕产品，生殖道和盆腔感染，输血,瘘管和邻近的病变,局部血肿,流产失败,入住重症监护病房或死亡。在索引住院期间和随后的住院期间监测这些事件长达90天。次要结果包括与手术无直接关系的一般不良事件。
结果：在112,842次住院中，4,951（4.39％）发生手术相关不良事件，256（0.23％）发生一般不良事件。多变量分析显示体积与结果的关系，在非常大量的情况下，手术相关的不良事件发生率较低(2.25%，OR=0.34,95CI[0.29-0.39],p<0.001)，高容量（4.24%，OR=0.61，95CI[0.55-0.69]，p<0.001)，和低容量(4.69%，OR=0.81,95CI[0.75-0.88],当与非常低体积的中心(6.65%)相比时,p<0.001)。个人社会经济地位(aOR=1.69，95CI[1.47-1.94]，p<0.001)，邻里剥夺(aOR=1.31，95%CI[1.22-1.39]，p<0.001)，和合并症（aOR=1.79，95CI[1.35-2.38]，p<0.001）与手术相关的不良事件有关。相反，一般不良事件的多变量分析未显示任何容量与结局的关系.
结论：容量-结果关系的存在强调了在低容量中心需要加强安全标准，以确保手术流产期间妇女安全的公平性。然而,我们的研究结果还强调了这种安全问题的复杂性,它涉及多种其他因素,包括社会经济地位和决策者必须考虑的合并症.
