30 天内非计划性再住院质量指标的推导和验证，以评估创伤护理。
Derivation and validation of a quality indicator for 30-day unplanned hospital readmission to evaluate trauma care.
机构信息
From the Department of Social and Preventative Medicine (L.M., A.F.T.), and Axe Santé des Populations-Pratiques Optimales en Santé (Population Health-Practice-changing Research Unit) (L.M., A.F.T., A.L.), Traumatologie, Urgence, Soins intensifs (Trauma, Emergency, Critical Care Medicine), Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec, Hôpital de l'Enfant-Jésus), Université Laval, Quebec; and Institut national d'excellence en santé et en services sociaux (G.B., J.L.), Montréal, Québec; Department of Critical Care Medicine, Medicine and Community Health Sciences (H.T.), Institute for Public Health, University of Calgary, Calgary, Alberta; and Department of Surgery (A.B.N.), St. Michael's Hospital, University of Toronto, Toronto, Canada.
出版信息
J Trauma Acute Care Surg. 2014 May;76(5):1310-6. doi: 10.1097/TA.0000000000000202.
BACKGROUND
Unplanned readmissions represent 20% of all admissions and cost $12 billion annually in the United States. Despite the burden of injuries for the health care system, no quality indicator (QI) based on readmissions is available to evaluate trauma care. The objective of this study was to derive and internally validate a QI for a 30-day unplanned hospital readmission to evaluate trauma care.
METHODS
We performed a multicenter retrospective cohort study in a Canadian integrated provincial trauma system. We included adults admitted to any of the 57 provincial trauma centers between 2005 and 2010 (n = 57,524). Data were abstracted from the provincial trauma registry and linked to the hospital discharge database. The primary outcome was unplanned readmission to an acute care hospital within 30 days of discharge. Candidate risk factors were identified by expert consensus and selected for derivation of the risk adjustment model using bootstrap resampling. The validity of the QI was evaluated in terms of interhospital discrimination, construct validity, and forecasting.
RESULTS
The risk adjustment model includes patient age, sex, the Injury Severity Score (ISS), region of the most severe injury, and 11 comorbid conditions. The QI discriminates well across trauma centers (coefficient of variation, 0.02) and is correlated with QIs that measure hospital performance in terms of clinical processes (r = -0.38), risk-adjusted mortality (r = 0.32), and complication rates (r = 0.38). In addition, performance in 2005 to 2007 was predictive of performance in 2008 to 2010 (r = 0.59).
CONCLUSION
We have developed a QI based on risk-adjusted 30-day rates of unplanned readmission, which can be used to evaluate trauma care with routinely collected data. The QI is based on a comprehensive risk adjustment model with good internal and temporal validity and demonstrates good properties in terms of discrimination, construct validity, and forecasting. This research represents an essential step toward reducing unplanned readmission rates to improve resource use and patient outcomes following injury.
LEVEL OF EVIDENCE
Prognostic study, level III.
背景
在美国，计划外再入院占所有入院人数的 20%，每年花费 120 亿美元。尽管伤病给医疗系统带来了负担，但目前还没有基于再入院的质量指标（QI）来评估创伤护理。本研究旨在制定并内部验证一个 30 天内非计划性住院再入院的 QI，以评估创伤护理。
方法
我们在加拿大省级综合创伤系统中进行了一项多中心回顾性队列研究。我们纳入了 2005 年至 2010 年间在 57 家省级创伤中心住院的成年人（n=57524）。数据从省级创伤登记处提取，并与医院出院数据库链接。主要结局是出院后 30 天内计划外再次入住急性护理医院。候选风险因素由专家共识确定，并通过自举重采样选择用于风险调整模型的推导。通过医院间的区分度、结构有效性和预测性来评估 QI 的有效性。
结果
风险调整模型包括患者年龄、性别、损伤严重程度评分（ISS）、最严重损伤部位和 11 种合并症。QI 在各创伤中心之间的区分度良好（变异系数为 0.02），并与衡量临床过程（r=-0.38）、风险调整死亡率（r=0.32）和并发症发生率（r=0.38）的医院绩效的 QI 相关。此外，2005 年至 2007 年的表现可以预测 2008 年至 2010 年的表现（r=0.59）。
结论
我们制定了一个基于风险调整后 30 天非计划性再入院率的 QI，可用于使用常规收集的数据评估创伤护理。QI 基于具有良好内部和时间有效性的综合风险调整模型，并在区分度、结构有效性和预测性方面表现出良好的特性。这项研究是朝着降低非计划性再入院率以改善创伤后资源利用和患者结局的方向迈出的重要一步。
证据水平
预后研究，III 级。
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