Fox Justin P, Vashi Anita A, Ross Joseph S, Gross Cary P
Department of Surgery, Boonshoft School of Medicine, Wright State University, Dayton, OH.
Department of Internal Medicine, Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine, New Haven, CT; Department of Veterans Affairs/VA Connecticut Healthcare System, West Haven, CT.
Surgery. 2014 May;155(5):743-53. doi: 10.1016/j.surg.2013.12.008. Epub 2013 Dec 14.
As a measure of quality, ambulatory surgery centers have begun reporting rates of hospital transfer at discharge. This process, however, may underestimate the acute care needs of patients after care. We conducted this study to determine rates and evaluate variation in hospital transfer and hospital-based, acute care within 7 days among patients discharged from ambulatory surgery centers.
Using data from the Healthcare Cost and Utilization Project, we identified adult patients who underwent a medical or operative procedure between July 2008 and September 2009 at ambulatory surgery centers in California, Florida, and Nebraska. The primary outcomes were hospital transfer at the time of discharge and hospital-based, acute care (emergency department visits or hospital admissions) within 7-days expressed as the rate per 1,000 discharges. At the ambulatory surgery center level, rates were adjusted for age, sex, and procedure-mix.
We studied 3,821,670 patients treated at 1,295 ambulatory surgery centers. At discharge, the hospital transfer rate was 1.1 per 1,000 discharges (95% confidence interval 1.1-1.1). Among patients discharged home, the hospital-based, acute care rate was 31.8 per 1,000 discharges (95% confidence interval 31.6-32.0). Across ambulatory surgery centers, there was little variation in adjusted hospital transfer rates (median = 1.0/1,000 discharges [25th-75th percentile = 1.0-2.0]), whereas substantial variation existed in adjusted, hospital-based, acute care rates (28.0/1,000 [21.0-39.0]).
Among adult patients undergoing ambulatory care at surgery centers, hospital transfer at time of discharge from the ambulatory care center is a rare event. In contrast, the rate of need for hospital-based, acute care in the first week afterwards is nearly 30-fold greater, varies across centers, and may be a more meaningful measure for discriminating quality.
作为一项质量衡量指标，门诊手术中心已开始报告出院时的医院转诊率。然而，这一过程可能低估了患者术后的急性护理需求。我们开展这项研究以确定门诊手术中心出院患者的医院转诊率，并评估7天内基于医院的急性护理情况及差异。
利用医疗成本和利用项目的数据，我们确定了2008年7月至2009年9月期间在加利福尼亚州、佛罗里达州和内布拉斯加州的门诊手术中心接受医疗或手术治疗的成年患者。主要结局指标为出院时的医院转诊率以及7天内基于医院的急性护理（急诊就诊或住院）率，以每1000例出院患者的比率表示。在门诊手术中心层面，对年龄、性别和手术组合进行了率的调整。
我们研究了1295家门诊手术中心治疗的3821670例患者。出院时，医院转诊率为每1000例出院患者1.1例（95%置信区间1.1 - 1.1）。在出院回家的患者中，基于医院的急性护理率为每1000例出院患者31.8例（95%置信区间31.6 - 32.0）。在各门诊手术中心之间，调整后的医院转诊率差异不大（中位数 = 每1000例出院患者1.0例[第25 - 75百分位数 = 1.0 - 2.0]），而调整后的基于医院的急性护理率存在显著差异（每1000例出院患者28.0例[21.0 - 39.0]）。
在门诊手术中心接受非住院治疗的成年患者中，门诊护理中心出院时的医院转诊是罕见事件。相比之下，此后第一周基于医院的急性护理需求率高出近30倍，各中心之间存在差异，并且可能是区分质量的更有意义的指标。
