■已知手术量会影响抢救失败(FTR),定义为并发症后死亡。机器人肺手术继续扩大,医院之间的结果存在差异。我们试图估计基于医院的因素对机器人右上叶切除术(RRUL)后结果和FTR的贡献。
■使用医疗保险和医疗补助服务中心住院索赔数据库,我们评估了2018年1月至2020年12月期间接受RRUL的所有年龄≥65岁且诊断为肺癌的患者.我们排除了接受过节段切除术的患者,叶下,楔形,或支气管增生切除术;有转移性或非恶性疾病;或有新辅助化疗史。主要结果包括FTR率,停留时间(LOS)再入院,转换为开放手术,并发症,和成本。我们按容量和医疗保险死亡率指数(MMI)的三分位数分析了医院。定义为每个幸存者的机构死亡人数,MMI是医院整体绩效和质量的标志。使用拟合优度对倾向评分模型进行了混杂调整。
■分析了4317例接受机器人右上叶切除术的患者的数据。医院按病例量分类(低,<9;中等,9-20;高,>20)和MMI(低,<0.04;中等,0.04-0.13;高,>0.13)。在倾向得分平衡后,来自最低容量和最高MMI的三分位数患者的费用较高(34,222美元vs30,316美元;P=.006),以及更高的死亡率(赔率比,7.46;95%置信区间,2.67-28.2;P<.001)。与高容量中心相比,低容量中心向开放手术的转化率较高,呼吸衰竭,出血性贫血,和死亡;LOS更长;成本更高(全部P<.001)。作为总死亡率预测指标的体积C统计量为0.6,而FTR为0.8。MMI最高三位数的医院转换为开放手术的比率最高(P=0.01),气胸(P=.02),呼吸衰竭(P<0.001)。他们的死亡率和再入院率也最高,最长的LOS,和最大的成本(P<.001)和最短的生存(P<.001)。作为总死亡率预测因子的MMI的C统计量为0.8,而FTR为0.9。
■MMI将基于医院的因素纳入结果的判断中,是比单独的FTR率更敏感的预测指标。组合MMI和体积可以提供可以在寻求实施机器人肺手术计划的医院中指导质量改进和成本效益措施的度量。
UNASSIGNED: Surgical volume is known to influence failure to rescue (FTR), defined as death following a complication. Robotic lung surgery continues to expand and there is variability in outcomes among hospitals. We sought to estimate the contribution of hospital-based factors on outcomes and FTR following robotic right upper lobectomy (RRUL).
UNASSIGNED: Using the Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all patients age ≥65 years with a diagnosis of lung cancer who underwent RRUL between January 2018 and December 2020. We excluded patients who had undergone segmentectomy, sublobar, wedge, or bronchoplastic resection; had metastatic or nonmalignant disease; or had a history of neoadjuvant chemotherapy. Primary outcomes included FTR rate, length of stay (LOS), readmissions, conversion to open surgery, complications, and costs. We analyzed hospitals by tertiles of volume and Medicare Mortality Index (MMI). Defined as the institutional number of deaths per number of survivors, MMI is a marker of overall hospital performance and quality. Propensity score models were adjusted for confounding using goodness of fit.
UNASSIGNED: Data for 4317 patients who underwent robotic right upper lobectomy were analyzed. Hospitals were categorized by volume of cases (low, <9; medium, 9-20; high, >20) and MMI (low, <0.04; medium, 0.04-0.13; high, >0.13). After propensity score balancing, patients from tertiles of lowest volume and highest MMI had higher costs ($34,222 vs $30,316; P = .006), as well as higher mortality (odds ratio, 7.46; 95% confidence interval, 2.67-28.2; P < .001). Compared to high-volume centers, low-volume centers had higher rates of conversion to open surgery, respiratory failure, hemorrhagic anemia, and death; longer LOS; and greater cost (P < .001 for all). The C-statistic for volume as a predictor of overall mortality was 0.6, and the FTR was 0.8. Hospitals in the highest tertile of MMI had the highest rates of conversion to open surgery (P = .01), pneumothorax (P = .02), and respiratory failure (P < .001). They also had the highest mortality and rate of readmission, longest LOS, and greatest costs (P < .001 for all) and the shortest survival (P < .001). The C-statistic for MMI as a predictor of overall mortality was 0.8, and FTR was 0.9.
UNASSIGNED: The MMI incorporates hospital-based factors in the adjudication of outcomes and is a more sensitive predictor of FTR rates than volume alone. Combining MMI and volume may provide a metric that can guide quality improvement and cost-effectiveness measures in hospitals seeking to implement robotic lung surgery programs.