Schultz Ellen M, Powell Adam A, McMillan Alex, Olsson Julie K, Enderle Mark A, Graham Barry A, Ordin Diana L, Gould Michael K
Center for Primary Care and Outcomes Research, Stanford School of Medicine, Stanford, California, USA.
Am J Respir Crit Care Med. 2009 Apr 1;179(7):595-600. doi: 10.1164/rccm.200806-890OC. Epub 2008 Oct 23.
Timeliness is one of six important dimensions of health care quality recognized by the Institute of Medicine.
To evaluate timeliness of lung cancer care and identify institutional characteristics associated with timely care within the Veterans Affairs (VA) health care system.
We used data from a VA nation-wide retrospective chart review and an independent audit of VA cancer programs to examine the association between time to first treatment and potentially explanatory institutional characteristics (e.g., volume of lung cancer patients) for 2,372 veterans diagnosed with lung cancer between 1 January 2002 and 1 September 2005 at 127 VA medical centers. We developed linear mixed effects models to control for clustering of patients within hospitals and we stratified analyses by stage.
Median time to treatment varied widely between (23 to 182 d) and within facilities. Median time to treatment was 90 days in patients with stage I or II cancer and 52 days in those with more advanced disease (P < 0.0001). Factors associated with shorter times to treatment included a nonacademic setting and the existence of a specialized diagnostic clinic (in patients with limited-stage disease), performing a patient flow analysis (in patients with advanced disease), and leadership beliefs about providing timely care (in both groups). However, institutional characteristics explained less than 1% of the observed variation in treatment times.
Time to lung cancer treatment in U.S. veterans is highly variable. The numerous institutional characteristics we examined explained relatively little of this variability, suggesting that patient, clinician, and/or unmeasured institutional characteristics may be more important determinants of timely care.
及时性是美国医学研究所认可的医疗质量六个重要维度之一。
评估肺癌治疗的及时性，并确定退伍军人事务部（VA）医疗系统中与及时治疗相关的机构特征。
我们使用了VA全国范围回顾性病历审查的数据以及对VA癌症项目的独立审计，来研究2002年1月1日至2005年9月1日期间在127个VA医疗中心被诊断为肺癌的2372名退伍军人的首次治疗时间与潜在解释性机构特征（如肺癌患者数量）之间的关联。我们开发了线性混合效应模型以控制医院内患者的聚集情况，并按阶段进行分层分析。
治疗时间中位数在不同机构（23至182天）和同一机构内差异很大。I期或II期癌症患者的治疗时间中位数为90天，病情更严重的患者为52天（P<0.0001）。与较短治疗时间相关的因素包括非学术环境以及存在专门的诊断诊所（局限期疾病患者）、进行患者流程分析（晚期疾病患者）以及领导层对提供及时治疗的信念（两组患者）。然而，机构特征对观察到的治疗时间差异的解释不到1%。
美国退伍军人的肺癌治疗时间差异很大。我们研究的众多机构特征对这种差异的解释相对较少，这表明患者、临床医生和/或未测量的机构特征可能是及时治疗更重要的决定因素。
