*Department of Pediatric Surgery, Children's Hospital Boston-Harvard Medical School, Boston, MA †Children's Hospital Association, Overland Park, KS.
Ann Surg. 2014 Jun;259(6):1228-34. doi: 10.1097/SLA.0000000000000246.
To characterize the scope and magnitude of practice variation associated with the diagnosis and treatment of appendicitis at freestanding children's hospitals.
Variation in care has been associated with poor outcomes and is believed to be a key driver of excess health care spending.
Retrospective cohort study of 13,328 patients treated with appendicitis at 34 children's hospitals (9/2010-9/2011). Patients were divided into complicated and uncomplicated cohorts and examined for interhospital variation in the use of diagnostic imaging (computed tomography or ultrasonography), laboratory tests, parenteral nutrition (PN), peripherally inserted central catheters (PICC), and hospital cost. The number and distribution of statistical outliers were calculated for all measures.
Significant variation was found for all measures, including a 3.5-fold difference in preoperative imaging (aggregate rate: 49.0%, range across hospitals: 21.2%-73.5%, P < 0.001) and a 5-fold difference in preoperative laboratory utilization (aggregate median: 2 tests/encounter, range: 1-5 tests/encounter, P < 0.001). For patients with complicated appendicitis, we characterized a 12-fold difference in postoperative imaging (aggregate rate: 19.4%, range: 4.9%-61.6%, P < 0.001), a 48-fold difference in PICC lines (aggregate rate: 18.9%, range: 1.7%-81.8%, P < 0.001), and a 100-fold difference in PN utilization (aggregate rate: 9.3%, range: 0.4%-42.0%, P < 0.001). Median hospital cost differed 4-fold for patients with uncomplicated disease (aggregate median: $6804, range: $4200-$16,796, P < 0.001) and 4.6-fold for patients with complicated disease (aggregate median: $13,138, range: $5419-$24,779, P < 0.001). Statistical outliers on the basis of high and low utilization were identified for all measures.
Significant variation exists in practice, resource utilization, and treatment-related cost associated with the management of appendicitis at freestanding children's hospitals. Value-based measures are needed for benchmarking and to prioritize collaborative quality improvement efforts.
描述与独立儿童医院阑尾炎诊治相关的实践差异的范围和程度。
护理差异与不良结局有关，被认为是医疗保健支出过度的关键驱动因素。
对 34 家儿童医院（2010 年 9 月至 2011 年 9 月）的 13328 例阑尾炎患者进行回顾性队列研究。患者分为复杂和不复杂队列，并检查诊断成像（计算机断层扫描或超声）、实验室检查、肠外营养（PN）、外周插入中心导管（PICC）和医院费用的使用方面的医院间差异。所有措施的统计异常值的数量和分布都进行了计算。
所有措施都发现了显著差异，包括术前影像学检查差异 3.5 倍（总发生率：49.0%，医院间范围：21.2%-73.5%，P<0.001）和术前实验室利用差异 5 倍（总中位数：2 项/次就诊，范围：1-5 项/次就诊，P<0.001）。对于患有复杂阑尾炎的患者，我们描述了术后影像学检查差异 12 倍（总发生率：19.4%，范围：4.9%-61.6%，P<0.001），PICC 线差异 48 倍（总发生率：18.9%，范围：1.7%-81.8%，P<0.001）和 PN 利用差异 100 倍（总发生率：9.3%，范围：0.4%-42.0%，P<0.001）。无并发症疾病患者的医院费用中位数差异 4 倍（总中位数：6804 美元，范围：4200-16796 美元，P<0.001），有并发症疾病患者的医院费用中位数差异 4.6 倍（总中位数：13138 美元，范围：5419-24779 美元，P<0.001）。所有措施均确定了高和低利用率的统计异常值。
在独立儿童医院管理阑尾炎方面，实践、资源利用和治疗相关成本存在显著差异。需要基于价值的措施进行基准测试，并优先进行协作质量改进工作。
