Gooiker Gea A, Veerbeek Laetitia, van der Geest Lydia G M, Stijnen Theo, Dekker Jan Willem T, Nortier J W R Hans, Marinelli Andreas W K S, Struikmans Henk, Wouters Michel W J M, Tollenaar Rob A E M
Leids Universitair Medisch Centrum, Afd. Heelkunde, Leiden, The Netherlands.
Ned Tijdschr Geneeskd. 2010;154:A1142.
To determine whether the quality indicator 'tumour positive surgical margin following breast-conserving surgery, consistently measured the quality of breast-cancer surgery independently of the different definitions used and differences in case mix, taking statistical random variation into account.
Descriptive study.
Data was collected from 762 patients who underwent breast-conserving surgery for invasive or in situ carcinoma of the breast, in the period 1 July 2007 - 30 June 2008 in 1 of the 9 hospitals in the region of the Comprehensive Cancer Centre West in the Netherlands. We compared 3 definitions for 'tumour positive surgical margin': the one used by the Health Care Inspectorate, the one used by the organisation 'Zichtbare Zorg' ('transparent care') and the percentage of re-resection. For case mix correction we identified risk factors for tumour margin positivity with logistic regression. The results were presented in a funnel plot, using 95% confidence interval (CI) around the national standard of 20%.
Depending on the definition used, the tumour positive surgical margin rate of the total group varied from 11 to 21%. Individual hospital rates varied by up to 19%. In situ carcinoma was associated with higher tumour positive surgical margin rates. Results differed significantly between hospitals for all 3 definitions. However, the funnel plot showed that results for most hospitals fell within the 95% CI of the standard. Whether a hospital fell within the 95% CI of the standard depended upon on the definition used and case mix correction.
The lack of a single definition for the quality indicator 'tumour positive surgical margin following breast-conserving surgery' and the lack of case-mix correction undermine the validity of the indicator. Standardisation of definitions, uniform registration and the use of funnel plots can provide a more transparent insight into the quality of care.
确定质量指标“保乳手术后肿瘤切缘阳性”是否能在考虑统计随机变异的情况下，独立于所使用的不同定义及病例组合差异，持续衡量乳腺癌手术的质量。
描述性研究。
收集了2007年7月1日至2008年6月30日期间在荷兰西部综合癌症中心区域的9家医院中的1家接受保乳手术治疗浸润性或原位乳腺癌的762例患者的数据。我们比较了“肿瘤切缘阳性”的3种定义：医疗保健检查局使用的定义、“透明医疗”组织使用的定义以及再次切除的百分比。对于病例组合校正，我们通过逻辑回归确定肿瘤切缘阳性的风险因素。结果以漏斗图呈现，使用围绕20%国家标准的95%置信区间（CI）。
根据所使用的定义，整个组的肿瘤切缘阳性率在11%至21%之间变化。各医院的个体率差异高达19%。原位癌与较高的肿瘤切缘阳性率相关。对于所有3种定义，各医院的结果差异显著。然而，漏斗图显示大多数医院的结果落在标准的95%CI范围内。一家医院是否落在标准范围取决于所使用的定义和病例组合校正。
质量指标“保乳手术后肿瘤切缘阳性”缺乏单一的定义以及病例组合校正，破坏了该指标的有效性。定义的标准化、统一登记以及使用漏斗图可以更透明地洞察医疗质量。
