Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229-3900, USA.
Med Care. 2013 Jan;51(1):60-7. doi: 10.1097/MLR.0b013e318270ba0d.
Over the past 20 years, surgical practice organizations have recommended the identification of ≥12 lymph nodes from surgically treated colon cancer patients as an indicator of quality performance for adequate staging; however, studies suggest that significant variation exists among hospitals in their level of adherence to this recommendation. We examined hospital-level factors that were associated with institutional improvement or maintenance of adequate lymph node evaluation after the introduction of surgical quality guidelines.
Using the 1996-2007 SEER-Medicare data, we evaluated hospital characteristics associated with short-term (1999-2001), medium-term (2002-2004), and long-term (2005-2007) guideline-recommended (≥12) lymph node evaluation compared with initial evaluation levels (1996-1998) using χ tests and multivariate logistic regression analysis, adjusting for patient case-mix.
We identified 228 hospitals that performed ≥6 colon cancer surgeries during each study period from 1996-2007. In the initial study period (1996-1998), 26.3% (n=60) of hospitals were performing guideline-recommended evaluation, which increased to 28.1% in 1999-2001, 44.7% in 2002-2004, and 70.6% in 2005-2007. In multivariate analyses, a hospital's prior guideline performance [odds ratio (OR) (95% confidence interval (CI)): 4.02 (1.92, 8.42)], teaching status [OR (95% CI): 2.33 (1.03, 5.28)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 3.39 (1.39, 8.31)] were significantly associated with short-term guideline-recommended lymph node evaluation. Prior hospital performance [OR (95% CI): 2.41 (1.17, 4.94)], urban location [OR (95% CI): 2.66 (1.12, 6.31)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 6.05 (2.32, 15.77)] were associated with medium-term performance; however, these factors were not associated with long-term performance.
Over the 12-year period, there were marked improvements in hospital performance for guideline-recommended lymph node evaluation. Understanding patterns in improvement over time contributes to debates over optimal designs of quality-improvement programs.
在过去的 20 年中，外科实践组织建议从接受手术治疗的结肠癌患者中识别出≥12 个淋巴结，作为充分分期的质量表现指标；然而，研究表明，医院在遵守这一建议的水平上存在显著差异。我们研究了与外科质量指南引入后机构改进或维持适当淋巴结评估相关的医院水平因素。
利用 1996-2007 年 SEER-医疗保险数据，我们使用 χ 检验和多变量逻辑回归分析，评估了与初始评估水平（1996-1998 年）相比，短期（1999-2001 年）、中期（2002-2004 年）和长期（2005-2007 年）指南推荐（≥12 个）淋巴结评估相关的医院特征，调整了患者病例组合。
我们确定了 1996-2007 年期间每个研究期间进行≥6 例结肠癌手术的 228 家医院。在初始研究期间（1996-1998 年），26.3%（n=60）的医院进行了指南推荐的评估，到 1999-2001 年增加到 28.1%，2002-2004 年增加到 44.7%，2005-2007 年增加到 70.6%。多变量分析显示，医院既往指南执行情况[比值比（OR）（95%置信区间（CI））：4.02（1.92，8.42）]、教学地位[OR（95%CI）：2.33（1.03，5.28）]和美国外科医师学会肿瘤学组成员[OR（95%CI）：3.39（1.39，8.31）]与短期指南推荐的淋巴结评估显著相关。既往医院绩效[OR（95%CI）：2.41（1.17，4.94）]、城市位置[OR（95%CI）：2.66（1.12，6.31）]和美国外科医师学会肿瘤学组成员[OR（95%CI）：6.05（2.32，15.77）]与中期表现相关；然而，这些因素与长期表现无关。
在 12 年期间，医院在指南推荐的淋巴结评估方面的表现有了显著提高。了解随时间改进的模式有助于围绕质量改进计划的最佳设计展开辩论。
