Gibbs J, Clark K, Khuri S, Henderson W, Hur K, Daley J
Cooperative Studies Program Coordinating Center, The Edward Hines Jr VA Hospital, Hines, IL 60141-5151, USA.
Int J Qual Health Care. 2001 Jun;13(3):187-96. doi: 10.1093/intqhc/13.3.187.
The primary purpose of this study was to validate risk-adjusted surgical outcomes as indicators of the quality of surgical care at US Department of Veterans Affairs (VA) hospitals. The secondary purpose was to validate the risk-adjustment models for screening cases for quality review.
We compared quality of care, determined by structured implicit chart review, for patients from hospitals with higher and lower than expected operative mortality and morbidity (hospital-level tests) and between patients with high and low predicted risk of mortality and morbidity who died or developed complications (patient-level tests).
739 general, peripheral vascular and orthopedic surgery cases sampled from the 44 VA hospitals participating in the National VA Surgical Risk Study.
A global rating of quality of care based on chart review.
Ratings of overall quality of care did not differ significantly between patients from hospitals with higher and lower than expected mortality and morbidity. On some of the secondary measures, patient care was rated higher for hospitals with lower than expected operative mortality. At the patient level of analysis, those who died or developed complications and had a high predicted risk of mortality or morbidity were rated higher on quality of care than those with a low predicted risk of adverse outcome.
The absence of a relationship between most of our measures of process of care and risk-adjusted outcomes may be due to an insensitivity of chart reviews to hospital-level differences in quality of care. Site visits to National VA Surgical Risk Study hospitals with high and low risk-adjusted mortality and morbidity have detected differences on a number of dimensions of quality. The patient-level findings suggest that the risk-adjustment models are useful for screening adverse outcome cases for quality of care review.
本研究的主要目的是验证经风险调整后的手术结果，作为美国退伍军人事务部（VA）医院外科护理质量的指标。次要目的是验证用于筛选病例进行质量审查的风险调整模型。
我们通过结构化的隐性病历审查，比较了手术死亡率和发病率高于或低于预期的医院患者的护理质量（医院层面测试），以及死亡或发生并发症的预测死亡和发病风险高与低的患者之间的护理质量（患者层面测试）。
从参与国家VA手术风险研究的44家VA医院中抽取的739例普通外科、外周血管外科和骨科手术病例。
基于病历审查的护理质量综合评分。
死亡率和发病率高于或低于预期的医院患者，其总体护理质量评分无显著差异。在一些次要指标上，手术死亡率低于预期的医院，患者护理评分更高。在患者层面的分析中，那些死亡或发生并发症且预测死亡或发病风险高的患者，其护理质量评分高于预测不良结局风险低的患者。
我们大多数护理过程指标与经风险调整后的结果之间缺乏关联，可能是由于病历审查对医院层面护理质量差异不敏感所致。对国家VA手术风险研究中风险调整后死亡率和发病率高与低的医院进行实地考察，发现了质量在多个维度上的差异。患者层面的研究结果表明，风险调整模型有助于筛选不良结局病例进行护理质量审查。
