Department of Social and Preventative Medicine, Centre de Recherche du CHU (Hôpital de l'Enfant- Jésus), Université Laval, Québec City, Québec, Canada.
J Trauma Acute Care Surg. 2013 May;74(5):1344-50. doi: 10.1097/TA.0b013e31828c32f2.
Process performance indicators that evaluate trauma centers in clinical case management provide information essential to the improvement of trauma care. However, multiple indicators are needed to adequately evaluate process performance, which renders comparisons cumbersome. Several methods are available for generating composite indicators that measure global performance. The goal of this study was to compare three composite methods that are widely used in other health care domains to identify the most appropriate for trauma care process performance evaluation.
In this retrospective, multicenter cohort study, 15 process performance indicators were implemented using data from a Canadian provincial trauma registry (19,853 patients; 59 centers) on patients with an Injury Severity Score (ISS) greater than 15. Composite scores were derived using three methods as follows: the indicator average, the opportunity model, and a latent variable model. Composite scores were evaluated in terms of discrimination, construct validity (association with an indicator of trauma center structural performance), criterion predictive validity (association with clinical outcomes), and forecasting (correlation over time).
All composite scores discriminated well between trauma centers. Only the average indicator score was correlated with improved structure (r = 0.29; 95% confidence interval [CI], 0.07-0.53), lower risk-adjusted mortality (r = -0.22; 95% CI, -0.46 to 0.04), and lower risk-adjusted complication rate (r = -0.48; 95% CI, -0.65 to -0.25). Composite scores calculated with 1999 to 2002 data all correlated with those calculated with 2003 to 2006 data (r = 0.49, 0.87, and 0.84 for the indicator average, the opportunity model, and the latent variable model, respectively).
Results suggest that of the three composite scores evaluated, only the indicator average demonstrates content and predictive criterion validity, discriminates between centers, and has good forecasting properties. In addition, this score is simple and intuitive and not subject to variation in weights over trauma systems and time. The observed association between higher indicator average scores and lower risk-adjusted mortality and complication rates suggests that improving process performance may improve patient outcome.
评估创伤中心临床病例管理的过程绩效指标为改善创伤护理提供了至关重要的信息。然而，需要多个指标才能充分评估过程绩效，这使得比较变得繁琐。有几种方法可用于生成衡量整体绩效的综合指标。本研究的目的是比较三种广泛应用于其他医疗保健领域的综合方法，以确定最适合创伤护理过程绩效评估的方法。
这是一项回顾性、多中心队列研究，使用来自加拿大省级创伤登记处（ISS 大于 15 的 19853 名患者；59 个中心）的数据实施了 15 个过程绩效指标。使用以下三种方法得出综合评分：指标平均值、机会模型和潜在变量模型。根据区分度、结构性能（与创伤中心结构性能指标的关联）、标准预测有效性（与临床结果的关联）和预测能力（随时间的相关性）对综合评分进行评估。
所有综合评分都能很好地区分创伤中心。只有平均指标得分与结构改善（r = 0.29；95%置信区间 [CI]，0.07-0.53）、风险调整死亡率降低（r = -0.22；95%CI，-0.46 至 0.04）和风险调整并发症发生率降低（r = -0.48；95%CI，-0.65 至 -0.25）相关。使用 1999 年至 2002 年数据计算的综合评分与使用 2003 年至 2006 年数据计算的综合评分均相关（指标平均值、机会模型和潜在变量模型的 r 值分别为 0.49、0.87 和 0.84）。
结果表明，在所评估的三种综合评分中，只有指标平均值具有内容和预测标准有效性、区分中心的能力以及良好的预测属性。此外，该评分简单直观，不受创伤系统和时间变化权重的影响。观察到较高的指标平均值得分与较低的风险调整死亡率和并发症发生率之间的关联表明，提高过程绩效可能会改善患者的预后。
