Vascular Surgery Department, Hospital Del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain.
Eur J Vasc Endovasc Surg. 2011 May;41(5):679-84. doi: 10.1016/j.ejvs.2011.01.003. Epub 2011 Feb 17.
Quality of care and learning effect surveillance are two mandatory responsibilities within a changing therapeutical paradigm. We aimed to evaluate the feasibility and value of CUSUM chart method in assessing performance in consecutive endovascular procedures done by vascular surgeons of a single department on aorto-iliac, femoropopliteal and renal artery occlusive disease.
Data were collected in 405 consecutive patients, scheduled for endovascular intervention of aorto-iliac (n = 131, 32.3%), femoropopliteal (n = 142, 35%) and renal artery (n = 132, 32.7%) occlusive disease during a 6-year period. Quality indicators included inability to cross the lesion, peri- and post-procedural complications and significant residual stenosis or occlusion at 1 month. CUSUM curves were generated for each territory globally and according to each quality indicator. The relevance of curve upward inflections was evaluated with Fisher's Exact Test.
Failure to cross the lesion occurred in 6.9% (aorto-iliac), 10.6% (femoropopliteal) and 2.3% (renal) of patients. One-hundredth twenty aorto-iliac, 127 femoropopliteal and 132 renal angioplasties were finally performed. Peri- and post-procedural complications appeared in 14.5% (aorto-iliac), 9.2% (femoropopliteal) and 2.3% (renal), while significant residual stenosis or occlusion was seen in 0.8%, 4.9% and 2.3% of patients, respectively. Aorto-iliac CUSUM curve showed two upward inflections at the beginning and the end of the period, both associated with peri- and post-procedural complications (p = 0.002 and p = 0.0013) and the latter also with failure to cross the lesion (p = 0.009). Femoro-popliteal CUSUM curve moved progressively upward during all the period, initially related to peri- and post-procedural complications (p = 0.038) and later to failure to cross the lesion (p = 0.004). Renal CUSUM curve didn't show any upward inflection during the analysed period.
CUSUM curves are an excellent tool for measuring learning effect and quality of care within a changing paradigm, such it is the case of endovascular interventions. Curve upward inflections can be further interpreted according to the type of "failure" thus helping to evaluate their underlying causes.
在不断变化的治疗模式下，医疗质量和学习效果监测是两项强制性职责。我们旨在评估累计和图（CUSUM）方法在评估血管外科医生对单一部门进行的腹主动脉-髂动脉、股腘动脉和肾动脉闭塞性疾病连续血管内治疗中的表现的可行性和价值。
在 6 年期间，共对 405 例连续患者进行了腹主动脉-髂动脉（n=131，32.3%）、股腘动脉（n=142，35%）和肾动脉（n=132，32.7%）闭塞性疾病的血管内干预。质量指标包括无法穿过病变、围手术期和术后并发症以及 1 个月时明显的残余狭窄或闭塞。为每个区域以及每个质量指标生成 CUSUM 曲线。Fisher 精确检验评估曲线向上弯曲的相关性。
病变无法通过的发生率为 6.9%（腹主动脉-髂动脉）、10.6%（股腘动脉）和 2.3%（肾动脉）。127 例腹主动脉-髂动脉、132 例股腘动脉和 132 例肾血管成形术最终进行。围手术期和术后并发症发生率分别为 14.5%（腹主动脉-髂动脉）、9.2%（股腘动脉）和 2.3%（肾动脉），而残余狭窄或闭塞的发生率分别为 0.8%、4.9%和 2.3%。腹主动脉-髂动脉 CUSUM 曲线在该时期开始和结束时出现两次向上弯曲，均与围手术期和术后并发症相关（p=0.002 和 p=0.0013），后者还与病变无法通过相关（p=0.009）。股腘动脉 CUSUM 曲线在整个时期持续向上移动，最初与围手术期和术后并发症相关（p=0.038），后来与病变无法通过相关（p=0.004）。肾动脉 CUSUM 曲线在分析期间没有出现任何向上弯曲。
CUSUM 曲线是衡量不断变化的治疗模式下学习效果和医疗质量的极好工具，如血管内介入治疗。曲线向上弯曲可以根据“失败”类型进一步解释，从而有助于评估其根本原因。
