与医院术后静脉血栓栓塞成像使用实践相关的医院因素评估。

Evaluation of hospital factors associated with hospital postoperative venous thromboembolism imaging utilisation practices.

作者信息

Chung Jeanette W, Ju Mila H, Kinnier Christine V, Haut Elliott R, Baker David W, Bilimoria Karl Y

机构信息

Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.

Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.

出版信息

BMJ Qual Saf. 2014 Nov;23(11):947-56. doi: 10.1136/bmjqs-2014-003150. Epub 2014 Aug 18.

DOI:10.1136/bmjqs-2014-003150

PMID:25136140

Abstract

BACKGROUND

Recent research suggests that hospital rates of postoperative venous thromboembolism (VTE) are subject to surveillance bias: the more hospitals 'look for' VTE, the more VTE they find. However, little is known about what drives variation in hospital VTE imaging rates. We conducted an observational study to examine hospital and market characteristics that were associated with hospital-level rates of postoperative VTE imaging, focusing on hospitals with particularly high rates.

METHODS

For Medicare beneficiaries undergoing 11 major operations (2009-2010) at 2820 hospitals, hospital-level postoperative VTE imaging use rates were calculated. Hospital characteristics associated with hospital VTE imaging use rates were examined including case severity, size, ownership, VTE process measure adherence, accreditations, staffing, malpractice environment, and county market factors. Associations between explanatory variables and VTE imaging rates were assessed using quantile regressions at the 25th, median, 75th and 90th quantiles.

RESULTS

Mean postoperative VTE imaging rates ranged from 85.26 (SD=67.38) per 1000 discharges in the lowest quartile of hospitals ranked by VTE imaging rates to 168.86 (SD=76.70) in the highest quartile. Drivers of high imaging rates at the 90th quantile were high resident-to-bed ratio (coefficient=51.35, p<0.01), Joint Commission accreditation (coefficient=19.05, p<0.01), presence of other hospitals in the same market with high imaging rates (coefficient=15.29, p<0.01), average case severity (coefficient=11.97, p<0.01), local malpractice costs (coefficient=11.29, p<0.01), and market competition (coefficient=11.03, p<0.01).

CONCLUSIONS

Hospital teaching status, resident-to-bed ratio, malpractice environment and local market factors drive hospital postoperative VTE imaging use, suggesting that non-clinical forces predominantly drive hospital VTE imaging practices.

摘要

背景

近期研究表明，医院术后静脉血栓栓塞症（VTE）发生率存在监测偏差：医院“查找”VTE的次数越多，发现的VTE就越多。然而，对于导致医院VTE成像率差异的原因知之甚少。我们进行了一项观察性研究，以检查与医院术后VTE成像率相关的医院和市场特征，重点关注成像率特别高的医院。

方法

对于在2820家医院接受11种主要手术（2009 - 2010年）的医疗保险受益人，计算了医院层面的术后VTE成像使用率。检查了与医院VTE成像使用率相关的医院特征，包括病例严重程度、规模、所有权、VTE流程指标依从性、认证、人员配备、医疗事故环境以及县市场因素。使用第25、中位数、第75和第90百分位数的分位数回归评估解释变量与VTE成像率之间的关联。

结果

术后VTE成像率中位数从VTE成像率排名最低四分位数的医院中每1000例出院患者85.26（标准差 = 67.38）到最高四分位数的168.86（标准差 = 76.70）不等。第90百分位数成像率高的驱动因素包括高住院医师与床位比（系数 = 51.35，p < 0.01）、联合委员会认证（系数 = 19.05，p < 0.01）、同一市场中其他成像率高的医院的存在（系数 = 15.29，p < 0.01）、平均病例严重程度（系数 = 11.97，p < 0.01）、当地医疗事故成本（系数 = 11.29，p < 0.01）以及市场竞争（系数 = 11.03，p < 0.01）。