ASA2013：血管外科修复主动脉瘤效果更理想

全美医院数据库的全面分析显示，就死亡率、住院时间和住院总费用等患者的主要结局而言，与心脏科医生或介入放射科医生相比，由血管外科医生实施腹主动脉瘤血管内修复术效果更佳。“显然这是令人震惊的发现，” 加州大学圣迭戈分校外科主任Mark A. Talamini教授在美国外科学会(ASA)2013年会上报告称，“我们认为应该考虑制定相关的卫生政策以支持动脉瘤修复患者的选择性转诊，或者考虑以更加有效的方式来实现介入科医生与血管外科医生之间的合作。”
Talamini教授所报告的这项结局分析研究总共纳入了28,094例接受腹主动脉瘤血管内支架植入术的患者，所有患者数据均来自2001~2009年全美住院患者样本。在美国卫生健康研究与质量机构的资助下，该数据库录入了由全美20%的医院组成的具有代表性的横断面数据。因此，Talamini教授及其同事可以清楚地知道实施手术的医生是血管外科医生、心脏科医生还是介入放射科医生。结果显示，78.1%的手术是由血管外科医生完成的，而其余手术则是由非外科的介入科医生完成的。97%的患者动脉瘤未破裂。
从主要结局指标来看，血管外科医生与介入科医生之间未经校正的差异是惊人的。在针对施术医生手术量、合并症、动脉瘤是否破裂、患者人口统计学特征和社会经济状况、医院位置、是否为教学医院等因素校正之后，差异愈加明显。介入科医生的患者死亡风险增加39%，总住院费用平均增加20,000万美元，住院时间延长1.4天。非血管科外科Talamini医生报道说，他是圣地亚哥加利弗尼亚大学外科教授及主席。
另一个值得关注的结果是，无论施术医生是什么专业，手术量较大的医生(定义为每年完成10台以上此类手术)其患者的死亡风险会下降31%。此外，手术量较大的医生还能使每位患者的总住院费用平均减少10,000美元，住院时间缩短1整天。在教学医院接受动脉瘤修复术对患者的死亡率和总住院费用均无明显影响，但与住院时间平均延长0.4天相关，他继续说。
针对上述差异Talamini医生提出了两种可能的解释。其一是血管外科医生和介入科医生的患者人群可能在某些方面存在差异，而这些差异没有纳入多因素分析当中。第二种可能性是由于血管外科医生的培训和手术经验更丰富，因此对治疗的判断会比介入科医生更准确，所以能获得更好的结局。“很明显这是一块孰优孰劣的讨论。我相信这不需要太多的其他这方面的证据。进一步的工作将利用纵向数据库对更多的细节作出阐释，以指导我们如何去做。” Talamini博士如是说。
评论员 K. Craig Kent教授认为这项研究的结果“非常具有争议性”。他说：“这项研究说明了医生对疾病的熟悉程度要比对技术的熟悉程度重要得多。” 美国威斯康辛大学麦迪逊分校外科主任Kent教授回忆说：“在25年前我刚刚出道成为一名血管外科医生时，这个专业还乏人问津，因为很少有人愿意去处理这样一些手术时间长且复杂、再次手术率高、手术结果往往也不够理想的患者。转眼间就到了2013年，现在血管外科医生、心脏科医生、介入放射科医生、肾脏科医生、皮肤科医生、血管内科医生等等都成为了人们梦寐以求的香脖脖。为何会发生如此大的变化？对于非外科医生而言，其原因是微创技术的发展使得任何专业的医生只要具备导管操作技能就可以参与到血管疾病的治疗当中。但是让非外科专业的医生来治疗血管疾病患者合适吗？这项研究给出了否定的答案。”
该研究的另一名作者 Samuel E. Wilson博士认为，患者选择是了解结局差异的关键。“血管外科医生在诊室里可以做出择期手术的决定，经过慎重考虑之后再决定是否要做这个手术。而医院的放射科医生可能就没有这样的机会，他可能接到电话说一名住院患者需要做这个手术，他觉得自己有责任去做。另一个关键因素可能是术后护理。血管外科患者可以在外科医生的指导下接受术后护理。” 加州大学欧文分校的血管外科医生Wilson观察到上述现象。
Wilson博士补充道，值得注意的是，血管外科医生和介入科医生的手术结局都有随时间逐渐改善的趋势。虽然两组医生的结局之间统计学差异持续存在，但的确随时间的推移在不断缩小。Robert S. Rhodes博士指出，将来有关腹主动脉瘤血管内修复的相对疗效研究还应该纳入普通外科。“ABS数据显示，普通外科医生实际上也开展了大量的血管外科手术，这可能是因为他们也掌握了血管内操作的技巧。” Rhodes博士是美国外科委员会(ABS)血管外科执行副主任。
所有报告者均声明无相关经济利益冲突。
与主动脉瘤相关的拓展阅读：

• Nat med：尼古丁促腹主动脉瘤形成
• JAMA :开放手术增加腹主动脉瘤死亡风险
• 中山大学孙逸仙纪念医院成功为90岁老人实施腹主动脉瘤腔内隔绝术
更多信息请点击：有关主动脉瘤更多资讯

Vascular surgeons get superior outcomes in aortic aneurysm repair
INDIANAPOLIS – Major outcomes in patients undergoing endovascular repair of abdominal aortic aneurysm are superior in terms of mortality, length of stay, and total hospital charges when the procedure is done by vascular surgeons rather than cardiologists or interventional radiologists, according to an analysis of a comprehensive national hospital database.

"Obviously these are striking findings," Dr. Mark A. Talamini noted in presenting the study results at the annual meeting of the American Surgical Association. "We believe that health policy in support of selective referrals for aneurysm repair, or integrating interventionalists and vascular surgeons more effectively, should be considered."

He presented an outcomes analysis involving 28,094 patients who underwent endovascular implantation of a graft for an abdominal aortic aneurysm within the Nationwide Inpatient Sample during 2001-2009. This database, sponsored by the Agency for Healthcare Research and Quality, receives input from a representative cross-section composed of 20% of U.S. hospitals. Dr. Talamini and coworkers were able to reliably determine whether an operator was a vascular surgeon, a cardiologist, or an interventional radiologist. Vascular surgeons performed 78.1% of the cases, while nonsurgeon interventionalists did the rest. Ninety-seven percent of patients presented with a nonruptured aneurysm.

The unadjusted differences in key outcomes between vascular surgeons and interventionalists were striking. Perhaps even more impressive were the differences following adjustment for operator volume, comorbid conditions, aneurysm rupture status, patient demographics and socioeconomic status, and hospital location and teaching status. The interventionalists’ patients had a 39% greater risk of mortality, an average of $20,000 more in total hospital charges, and a 1.4-day longer length of stay, reported Dr. Talamini, a nonvascular surgeon who is professor and chairman of the department of surgery at the University of California, San Diego.

Additional findings of interest were that the patients of high-volume operators (defined as those who performed more than 10 cases per year) had a 31% reduction in mortality risk regardless of operator specialty. In addition, high-volume operators averaged $10,000 per patient less in total hospital charges and shorter hospital length of stay by 1 full day. Undergoing aneurysm repair in a teaching hospital had no impact upon mortality or total charges, but was associated with an average 0.4-day greater length of stay, he continued.

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Dr. Talamini offered two potential explanations for the disparate outcomes. One is that perhaps the patient populations of vascular surgeons and interventionalists differ in ways that were not accounted for in the multivariate analysis. The other possibility is that vascular surgeons achieve better outcomes because their training and experience are superior, allowing them to make better judgments about treatment than those of interventionalists.

"Obviously, this is the ‘we’re better than they are’ argument, and I hardly think we can assume that this is the case until we exhaust all other potential explanations. Further work using longitudinal databases with more detail hopefully will allow us to do just that," said Dr. Talamini.

Discussant Dr. K. Craig Kent called the study findings "very provocative."

"The moral of the story is expertise in disease is far more important than expertise in technology," declared Dr. Kent, professor and chairman of the department of surgery at the University of Wisconsin, Madison.

"When I first became a vascular surgeon 25 years ago it was difficult to recruit to the specialty. There were few that wanted to care for a group of patients for whom procedures were long and tedious, reoperations were common, and outcomes weren’t always favorable," Dr. Kent recalled. "Fast forward to 2013, where everybody wants to be a vascular surgeon: cardiologists, interventional radiologists, nephrologists, dermatologists, vascular medicine physicians, and many others. Why the dramatic change? For the nonsurgeons, the reason is the development of minimally invasive technology that has allowed any specialist with catheter-based skills to participate in vascular care. But is it appropriate for nonsurgical specialists to treat vascular patients? The answer from this study is a resounding no."

Dr. Samuel E. Wilson, a vascular surgeon who was Dr. Talamini’s coinvestigator in the study, said he thinks patient selection is the key to understanding the outcome disparities.

"If you think about it, the vascular surgeon in his office has the ability to make an elective decision, carefully considered, and decide whether or not he’s going to actually do the procedure. The hospital-based radiologist may not have that opportunity; he receives a call, a procedure on an inpatient is requested, and he feels obligated to proceed. Another key aspect may be postoperative care. Vascular surgery patients receive their postoperative care under the direction of the surgeon," observed Dr. Wilson of the University of California, Irvine.

It’s worth noting, he added, that the outcomes for both vascular surgeons and interventionalists improved over the years of the study. The results are coming closer together over time, although significant differences remain.

Dr. Robert S. Rhodes said that general surgeons should be included in any further comparative effectiveness studies focused on endovascular repair of abdominal aortic aneurysms.

"Our data at the American Board of Surgery suggests that general surgeons who perform vascular surgery actually do so in substantial volume, so it may be that they’ve also acquired endovascular skills," said Dr. Rhodes, associate executive director for vascular surgery at the ABS.

None of the speakers reported having any financial conflicts.