髋关节和膝关节置换术后出院后静脉血栓栓塞对医院质量比较的影响。

Effect of post-discharge venous thromboembolism on hospital quality comparisons following hip and knee arthroplasty.

机构信息

Division of Research and Optimal Patient Care, American College of Surgeons, 633 North St. Clair Street, 22nd Floor, Chicago, IL 60611. E-mail address for K.Y. Bilimoria:

Department of Orthopaedic Surgery, Northwestern University, Galter Pavilion-Northwestern Memorial Hospital, 676 North St. Clair Street, Chicago, IL 60611.

出版信息

J Bone Joint Surg Am. 2014 Sep 3;96(17):1476-84. doi: 10.2106/JBJS.M.01248.

DOI:10.2106/JBJS.M.01248

PMID:25187587

Abstract

BACKGROUND

Symptomatic pre-discharge venous thromboembolism (VTE) rates after total or partial hip or knee arthroplasty have been proposed as patient safety indicators. However, assessing only pre-discharge VTE rates may be suboptimal for quality measurement as the duration of stay is relatively short and the VTE risk extends beyond the inpatient setting.

METHODS

Patients who underwent total or partial hip or knee arthroplasty were identified in the 2008 through 2010 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Outcomes of interest were the deep venous thrombosis (DVT), pulmonary embolism (PE), and overall VTE rates within thirty days after surgery and the rates during the pre-discharge and post-discharge portions of this time period. Risk-adjusted hospital rankings based on only pre-discharge (inpatient) events were compared with those based on both pre-discharge and post-discharge events within thirty days of surgery.

RESULTS

A total of 23,924 patients underwent total or partial hip arthroplasty (8499) or knee arthroplasty (15,425) at ninety-five hospitals. For hip arthroplasty, the VTE rate was 0.9%, with 57.9% of the events occurring after discharge. For knee arthroplasty, the VTE rate was 1.9%, with 38.3% of the events occurring after discharge. The median time of VTE occurrence was eleven days postoperatively for hip arthroplasty and three days for knee arthroplasty. The median duration of stay was three days for both hip and knee arthroplasty. When hospitals were ranked according to VTE rates, hospital outlier status designations changed when post-discharge events were included (κ = 0.386; 44% false-positive rate for low outliers). The median change in hospital quality ranking was 7 (interquartile range, 2 to 17), with a rank correlation of r = 0.82.

CONCLUSIONS

Nearly twice as many VTE complications were captured if both pre-discharge and post-discharge events were considered, and inclusion of post-discharge events changed hospital quality rankings. These data suggest that inclusion of post-discharge events should be considered when comparing the quality of hospitals on the basis of postoperative VTE rates.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

摘要

背景

全髋或全膝关节置换术后有症状的出院前静脉血栓栓塞症（VTE）发生率已被提议作为患者安全指标。然而，仅评估出院前 VTE 发生率可能并不适合质量测量，因为住院时间相对较短，VTE 风险超出了住院环境。

方法

在美国外科医师学院（ACS）国家手术质量改进计划（NSQIP）数据库中，确定了接受全髋或全膝关节置换术的患者。感兴趣的结果是术后 30 天内深静脉血栓形成（DVT）、肺栓塞（PE）和总 VTE 发生率以及该时间段内出院前和出院后的发生率。仅基于出院前（住院）事件的风险调整后的医院排名与基于术后 30 天内出院前和出院后事件的排名进行了比较。

结果

共有 23924 例患者在 95 家医院接受了全髋或全膝关节置换术（8499 例全髋置换术和 15425 例全膝关节置换术）。全髋置换术的 VTE 发生率为 0.9%，57.9%的事件发生在出院后。全膝关节置换术的 VTE 发生率为 1.9%，38.3%的事件发生在出院后。髋部手术后 VTE 发生的中位时间为术后 11 天，膝关节置换术为术后 3 天。髋膝关节置换术的中位住院时间均为 3 天。当根据 VTE 发生率对医院进行排名时，如果包括出院后事件，医院异常值的指定会发生变化（κ=0.386；低值异常值的假阳性率为 44%）。医院质量排名的中位数变化为 7（四分位间距，2 至 17），秩相关系数 r = 0.82。