Cohen M M, Duncan P G, Pope W D, Biehl D, Tweed W A, MacWilliam L, Merchant R N
Department of Anesthesia, University of Manitoba, Winnipeg, Canada.
Can J Anaesth. 1992 May;39(5 Pt 1):430-9. doi: 10.1007/BF03008706.
Since anaesthesia, unlike medical or surgical specialties, does not constitute treatment, this study sought to determine if methods used to assess medical or surgical outcomes (that is the determination of adverse outcome) are applicable to anaesthesia. Anaesthetists collected information on patient, surgical and anaesthetic factors while data on recovery room and postoperative events were evaluated by research nurses. Data on 27,184 inpatients were collected and the analysis of outcomes determined for the intraoperative, post-anaesthetic care unit and postoperative time periods. Logistic regression was used to control for differences in patient populations across the four hospitals. In addition, a random selection of 115 major events was classified by a panel of anaesthetists into anaesthesia, surgical and patient-disease contributions. Across the three time periods, large variations in minor outcomes were found across the four hospitals; these variations ranged from two- to five-fold after case-mix adjustment (age, physical status, sex, emergency versus elective and length of anaesthesia). The rates of major events and deaths were similar across three hospitals; one hospital had a lower mortality rate (P less than 0.001) but had a higher rate of all major events (P less than 0.0001). Of major events assessed by physician panels, 18.3% had some anaesthetic involvement and no deaths were attributable partially or wholly to anaesthesia. Possible reasons to account for these variations in outcome include compliance in recording events, inadequate case-mix adjustment, differences in interpretation of the variables (despite guidelines) and institutional differences in monitoring, charting and observation protocols. The authors conclude that measuring quality of care in anaesthesia by comparing major outcomes is unsatisfactory since the contribution of anaesthesia to perioperative outcomes is uncertain and that variations may be explained by institutional differences which are beyond the control of the anaesthetist. It is suggested that minor adverse events, particularly those of concern to the patient, should be the next focus for quality improvement in anaesthesia.
由于麻醉与医学或外科专业不同，并不构成治疗手段，因此本研究旨在确定用于评估医学或外科治疗结果（即确定不良结果）的方法是否适用于麻醉领域。麻醉医生收集了患者、手术和麻醉因素的信息，而恢复室和术后事件的数据则由研究护士进行评估。收集了27184例住院患者的数据，并对术中、麻醉后护理单元和术后时间段的结果进行了分析。采用逻辑回归来控制四家医院患者群体的差异。此外，一组麻醉医生将随机挑选的115起重大事件按麻醉、手术和患者疾病因素进行了分类。在三个时间段内，四家医院的次要结果存在很大差异；病例组合调整（年龄、身体状况、性别、急诊与择期手术以及麻醉时长）后，这些差异在两倍至五倍之间。三家医院的重大事件发生率和死亡率相似；一家医院的死亡率较低（P<0.001），但所有重大事件的发生率较高（P<0.0001）。在由医生小组评估的重大事件中，18.3%有一些麻醉因素参与，且没有死亡完全或部分归因于麻醉。导致这些结果差异的可能原因包括事件记录的依从性、病例组合调整不足、变量解释的差异（尽管有指南）以及监测、图表记录和观察方案的机构差异。作者得出结论，通过比较重大结果来衡量麻醉护理质量并不理想，因为麻醉对围手术期结果的贡献尚不确定，而且差异可能由麻醉医生无法控制的机构差异所解释。建议将轻微不良事件，尤其是患者关注的那些事件，作为麻醉质量改进的下一个重点。
