醫師、醫院PCI服務量閾值與死亡之關係

The relationship between physician and hospital PCI volume thresholds and mortality

目標：過去研究發現，醫師或醫院經皮冠狀動脈介入性治療（percutaneous coronary intervention, PCI）服務量與病人結果有關，美國心臟病學院、美國心臟學會及美國心血管造影和介入學會推薦，醫師與醫院服務量一年最少各為50及200例，以維持治療能力，然過去少有實證研究探討，醫師及醫院PCI服務量與病人結果間關係是否有服務量閾值存在，故本研究目的為決定PCI之醫師及醫院服務量與病人死亡關係間之閾值。方法：資料取自全民健康保險研究資料庫，研究對象為2009年接受PCI之病人，共30,905人。本研究以限制性立方截斷式（restricted cubic splines）模型，決定醫師及醫院PCI服務量與30日死亡關係之閾值，以多階層邏輯斯迴歸，控制病人、醫師及醫院特質後，檢測醫師及醫院服務量閾值對30日死亡之影響。結果：醫師PCI服務量達一年50例後，風險校正後30日死亡率下降趨勢呈現平滑，且病人由醫師執行PCI服務量達50例者醫治，相較未達50例者，有53.6%較低的30日死亡勝算。結論：病人由執行PCI一年達50例之醫師醫治，可降低死亡風險。

Objectives: Previous studies have found that physician volume or hospital volume has been associated with outcomes for percutaneous coronary intervention (PCI). The American College of Cardiology, The American Heart Association, and The Society for Cardiovascular Interventions recommend that the minimum annual PCI volumes for physicians and hospitals are 50 and 200 cases, respectively, in order to maintain competency. Few empirical studies have explored whether a relationship exists between physician or hospital PCI volume threshold and patient outcome; therefore, the objective of this study was to determine the relationship between physician and hospital PCI volume thresholds and mortality. Methods: This study used the Taiwan National Health Insurance Research Database. The study subjects were 30,905 patients who underwent PCI in 2009. A restricted cubic spline model was utilized to determine thresholds for the relationship between physician and hospital PCI volume and 30-day mortality. After adjustment for patient, physician, and hospital characteristics, a hierarchical mixed-effect logistic model was used to examine the impact of physician and hospital volume thresholds on 30-day mortality. Results: Once the annual physician volume reached 50 cases, the declining trend in risk-adjusted 30-day mortality rates began to flatten. Moreover, patients treated by physicians with volumes reaching 50 cases had 53.6% lower odds of 30-day mortality compared with those treated by physicians with volumes of fewer than 50 cases. Conclusions: Patients who are treated by physicians who perform 50 PCIs or more a year are at decreased risk for mortality.