Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, Praed Street, London W21NY, UK.
Gut. 2013 Mar;62(3):423-9. doi: 10.1136/gutjnl-2011-301489. Epub 2012 Feb 16.
To evaluate overall performance of English colorectal cancer surgical units identified as outliers for a single quality measure--30 day inhospital mortality.
144,542 patients that underwent primary major colorectal cancer resection between 2000/2001 and 2007/2008 in 149 English National Health Service units were included from hospital episodes statistics. Casemix adjusted funnel plots were constructed for 30 day inhospital mortality, length of stay, unplanned readmission within 28 days, reoperation, failure to rescue-surgical (FTR-S) and abdominoperineal excision (APE) rates. Institutional performance was evaluated across all other domains for institutions deemed outliers for 30 day mortality. Outliers were those that lay on or breached 3 SD control limits. 'Acceptable' performance was defined if units appeared under the upper 2 SD limit.
5 high mortality outlier (HMO) units and 15 low mortality outlier (LMO) units were identified. Of the five HMO units, two were substandard performance outliers (ie, above 3 SD) on another metric (both on high reoperation rates). A further two HMO institutions exceeded the second but not the third SD limits for substandard performance on other outcome metrics. One of the 15 LMO units exceeded 3 SD for substandard performance (APE rate). One LMO institution exceeded the second but not the third SD control limits for high reoperation rates. Institutional mortality correlated with FTR-S and reoperations (R=0.445, p<0.001 and R=0.191, p<0.020 respectively).
Performance appraisal in colorectal surgery is complex and dependent on stakeholder perspective. Benchmarking units solely on a single performance measure is over simplistic and potentially hazardous. A global appraisal of institutional outcome is required to contextualise performance.
评估被确定为单一质量指标——30 天住院死亡率异常值的英语结直肠肿瘤外科单位的总体表现。
从医院病例统计中纳入了 2000/2001 年至 2007/2008 年间在 149 个英国国民保健服务机构中接受主要结直肠肿瘤切除术的 144542 名患者。为了 30 天住院死亡率、住院时间、28 天内计划外再入院、再次手术、手术失败挽救-外科（FTR-S）和腹会阴切除术（APE）率，构建了病例组合调整的漏斗图。对于被认为 30 天死亡率异常值的机构，在所有其他领域评估机构的绩效。异常值是指位于或突破 3 个标准差控制限的机构。如果单位出现在 2 个标准差上限以下，则定义为“可接受”的表现。
确定了 5 个高死亡率异常值（HMO）单位和 15 个低死亡率异常值（LMO）单位。在这 5 个 HMO 单位中，有 2 个单位在另一个指标上表现不佳（即高于 3 个标准差）（均为高再次手术率）。另外两个 HMO 机构在其他结果指标上的表现不佳，超过了第二个但未超过第三个标准差限制。在 15 个 LMO 单位中，有 1 个单位的 APE 率超过 3 个标准差，表现不佳。有一个 LMO 机构的高再次手术率超过了第二个但未超过第三个标准差控制限。机构死亡率与 FTR-S 和再次手术相关（R=0.445，p<0.001 和 R=0.191，p<0.020）。
结直肠手术的绩效评估是复杂的，取决于利益相关者的观点。仅根据单一绩效指标对单位进行基准测试过于简单化，并且可能存在危险。需要对机构的整体结果进行评估，以了解其表现。
