Department of Surgery, College of Medicine, University of Vermont, Burlington, VT, USA.
Ann Surg. 2010 Sep;252(3):452-8; discussion 458-9. doi: 10.1097/SLA.0b013e3181f10a66.
OBJECTIVE(S): Profiling of hospitals using risk-adjusted mortality rates as a measure of quality is becoming increasingly frequent. We sought to determine the validity of this approach by comparing the risk-adjusted predicted mortality to the findings of concurrent peer review and retrospective chart review of deaths that occur on a general surgery service.
Consecutive patients admitted to a busy general surgery service from January 2000 to January 2006 were prospectively entered into the Surgical Activity Tracking System. Rigorous, systematic peer review was performed concurrently by service members on all deaths. Adjudication was later validated by an independent senior surgeon. Three methodologies of risk adjustment (University Health Consortium, Physiological and Operative Severity Score for the enUmeration of Mortality, and the Charlson index) were used and compared the "excess mortality" predicted by each to the number of potentially preventable deaths determined by peer review.
A total of 9623 patients were admitted and 75 died (0.7%). University Health Consortium and Physiological and Operative Severity Score predicted an excess mortality of 62 and 65 deaths, respectively; Charlson predicted that 73% of the cohort would be dead in 1 year. Concurrent and retrospective peer review found that death was potentially preventable in only 22 and 21 patients, respectively.
Peer adjudication and extensive clinical review adds much to the analysis of an adverse outcome, similar to the "black box" in an airplane crash. Although methods of risk adjustment may be helpful in identifying patients for peer review, they should be used for internal process improvement and not published as metrics of hospital or provider performance.
使用风险调整死亡率来评估医院的质量已经越来越普遍。我们旨在通过比较风险调整后的预测死亡率与同期同行评审和回顾性图表审查发现的死亡率，来确定这种方法的有效性，这些死亡率发生在普通外科服务中。
从 2000 年 1 月至 2006 年 1 月，连续入住繁忙的普通外科服务的患者被前瞻性地纳入手术活动跟踪系统。由服务成员对所有死亡病例进行严格、系统的同行评审。后来由一位独立的资深外科医生对裁决进行了验证。使用了三种风险调整方法（大学健康联盟、生理和手术严重程度评分用于死亡率计数以及 Charlson 指数），并将每种方法预测的“超额死亡率”与同行评审确定的潜在可预防死亡人数进行了比较。
共有 9623 名患者入院，75 人死亡（0.7%）。大学健康联盟和生理和手术严重程度评分分别预测有 62 和 65 例死亡是超额的；Charlson 预测该队列中有 73%的患者在 1 年内会死亡。同期和回顾性同行评审发现，只有 22 名和 21 名患者的死亡可能是可以预防的。
同行评审和广泛的临床审查为不良结果的分析增加了很多内容，类似于飞机失事的“黑匣子”。尽管风险调整方法可能有助于确定需要同行评审的患者，但它们应该用于内部流程改进，而不应作为医院或提供者绩效的指标进行发布。
