目的:在高手术量环境下,关于胃癌患者的集中化与护理质量之间的关联的证据有限。本研究旨在探讨医院数量和赫芬达尔-赫希曼指数(HHI)对住院死亡率的影响。总成本,以及全国数据库中中国胃切除术患者的住院时间。
方法:我们从2013年至2018年的医院质量监测系统数据库中提取了胃癌胃切除术的数据。医院容量分为4个四分位数:低(每年1-83例),中型(84-238例),高(239-579例),而且非常高(580-1,193例)。HHI分为3类:高度集中(>2500),中度集中(1,500-2,500),和不集中(<1,500)。我们使用混合效应模型来分析数据,同时考虑数据聚类。
结果:我们分析了515个机构的125,683名患者。在多变量分析中,医院数量与住院死亡率显著相关[中等与低:比值比(OR)=0.61,95%置信区间(95%CI)=0.43-0.84,P=0.003;高:OR=0.57,95%CI=0.38-0.87,P=0.009;非常高:OR=0.33,95%CI=0.18-0.61,P<0.001)和住院时间(高vs.低:β=-0.036,95%CI=-0.071--0.002,P=0.039),但不包括总成本。非集中省份医院的住院死亡率较高(OR=1.52,95%CI=1.03~2.26,P=0.036),住院时间较长(β=0.024,95%CI=0.001~0.047,P=0.041)。
结论:胃切除术的集中化,按医院容量和HHI衡量,在不增加总费用的情况下,与住院死亡率降低和住院时间缩短相关.这些结果支持在高容量环境中集中胃切除术的策略。
OBJECTIVE: Limited evidence is available regarding the associations of centralization with gastric cancer patients\' quality of care in high surgical volume settings. The current study aimed to explore the effects of hospital volume and the Herfindahl-Hirschman index (HHI) on in-hospital mortality, total cost, and length of stay for Chinese gastrectomy patients in a nationwide database.
METHODS: We extracted data on gastrectomy for gastric cancer from the Hospital Quality Monitoring System Database between 2013 and 2018. Hospital volume was divided into 4 quartiles: low (1-83 cases per year), medium (84-238 cases), high (239-579 cases), and very high (580-1,193 cases). The HHI was divided into 3 categories: highly concentrated (>2,500), moderately concentrated (1,500-2,500), and unconcentrated (<1,500). We used mixed-effects models to analyze the data while accounting for data clustering.
RESULTS: We analyzed 125,683 patients in 515 institutions. In the multivariable analyses, hospital volume was significantly associated with in-hospital mortality [medium vs. low: odds ratio (OR)=0.61, 95% confidence interval (95% CI)=0.43-0.84, P=0.003; high: OR=0.57, 95% CI=0.38-0.87, P=0.009; and very high: OR=0.33, 95% CI=0.18-0.61, P<0.001) and length of stay (highvs. low: β=-0.036, 95% CI=-0.071--0.002, P=0.039) but not with total cost. Hospitals located in unconcentrated provinces had higher in-hospital mortality (OR=1.52, 95% CI=1.03-2.26, P=0.036) and longer lengths of stay (β=0.024, 95% CI=0.001-0.047, P=0.041) than hospitals located in highly concentrated provinces.
CONCLUSIONS: Centralization of gastrectomy, measured by hospital volume and the HHI, was associated with decreased in-hospital mortality and shortened length of stay without increasing total cost. These results support the strategy of centralizing gastrectomy in high-volume settings.