仅基于死亡率对创伤中心进行基准测试不能反映护理质量：对按绩效付费的影响。
Benchmarking trauma centers on mortality alone does not reflect quality of care: implications for pay-for-performance.
机构信息
From the Center for Surgical Trials and Outcomes Research (Z.G.H., E.B.S., E.R.H., A.H.H.), and Division of Acute Care Surgery, Trauma, Emergency Surgery and Critical Care (E.R.H., A.H.H.), Department of Surgery, Department of Emergency Medicine (ERH), and Department of Anesthesiology and Critical Care Medicine (A.L.), The Johns Hopkins School of Medicine; and Department of Health Policy and Management (R.C., A.H.H.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and Department of Surgery (S.N.Z., E.C.C.), Howard University College of Medicine, Washington, District of Columbia.
出版信息
J Trauma Acute Care Surg. 2014 May;76(5):1184-91. doi: 10.1097/TA.0000000000000215.
BACKGROUND
Trauma centers are currently benchmarked on mortality outcomes alone. However, pay-for-performance measures may financially penalize centers based on complications. Our objective was to determine whether the results would be similar to the current standard method of mortality-based benchmarking if trauma centers were profiled on complications.
METHODS
We analyzed data from the National Trauma Data Bank from 2007 to 2010. Patients 16 years or older with blunt or penetrating injuries and an Injury Severity Score (ISS) of 9 or higher were included. Risk-adjusted observed-to-expected (O/E) mortality ratios for each center were generated and used to rank each facility as high, average, or low performing. We similarly ranked facilities on O/E morbidity ratios defined as occurrence of any major complication. Concordance between hospital performance rankings was evaluated using a weighted κ statistic. Correlation between morbidity- and mortality-based O/E ratios was assessed using Pearson coefficients. Sensitivity analyses were performed to mitigate the competing risk of death for the morbidity analyses.
RESULTS
A total of 449,743 patients from 248 facilities were analyzed. The unadjusted morbidity and mortality rates were 10.0% and 6.9%, respectively. No correlation was found between morbidity- and mortality-based O/E ratios (r = -0.01). Only 40% of the centers had similar performance rankings for both mortality and morbidity. Of the 31 high performers for mortality, only 11 centers were also high performers for morbidity. A total of 78 centers were ranked as average, and 11 ranked as low performers on both outcomes. Comparison of hospital performance status using mortality and morbidity outcomes demonstrated poor concordance (weighted κ = 0.03, p = 0.22).
CONCLUSION
Mortality-based external benchmarking does not identify centers with high complication rates. This creates a dichotomy between current trauma center profiling standards and measures used for pay-for-performance. A benchmarking mechanism that reflects all measures of quality is needed.
LEVEL OF EVIDENCE
Prognostic/epidemiologic study, level III.
背景
目前，创伤中心仅根据死亡率结果进行基准测试。然而，按绩效付费的措施可能会因并发症而对中心进行经济处罚。我们的目的是确定如果根据并发症对创伤中心进行分类，结果是否与目前基于死亡率的基准测试标准相似。
方法
我们分析了 2007 年至 2010 年国家创伤数据库的数据。纳入标准为年龄在 16 岁及以上、有钝器或穿透伤、损伤严重程度评分（ISS）为 9 或更高的患者。为每个中心生成了风险调整后的观察到的预期（O/E）死亡率比，并将每个机构排名为高、中、低绩效。我们同样根据任何主要并发症的发生情况，将设施排名为 O/E 发病率比。使用加权κ统计量评估医院绩效排名的一致性。使用 Pearson 系数评估发病率和死亡率 O/E 比之间的相关性。进行敏感性分析以减轻发病率分析中死亡的竞争风险。
结果
共分析了来自 248 家机构的 449743 名患者。未经调整的发病率和死亡率分别为 10.0%和 6.9%。未发现发病率和死亡率 O/E 比之间存在相关性（r=-0.01）。只有 40%的中心在死亡率和发病率方面的表现排名相似。在 31 个死亡率高的中心中，只有 11 个中心的发病率也较高。共有 78 家中心在两个结果中被评为平均水平，11 家中心被评为低水平。使用死亡率和发病率结果比较医院绩效状况显示一致性较差（加权κ=0.03，p=0.22）。
结论
基于死亡率的外部基准测试并不能确定高并发症发生率的中心。这在当前创伤中心档案标准和按绩效付费措施之间造成了二分法。需要一种反映所有质量措施的基准测试机制。
证据水平
预后/流行病学研究，III 级。
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