Reames Bradley N, Krell Robert W, Campbell Darrell A, Dimick Justin B
Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.
Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor2Surgical Innovation Editor, JAMA Surgery.
JAMA Surg. 2015 Mar 1;150(3):208-15. doi: 10.1001/jamasurg.2014.2873.
Previous studies of checklist-based quality improvement interventions have reported mixed results.
To evaluate whether implementation of a checklist-based quality improvement intervention--Keystone Surgery--was associated with improved outcomes in patients in a large statewide population undergoing general surgery.
DESIGN, SETTING, AND EXPOSURES: A retrospective longitudinal study examined surgical outcomes in 64,891 Michigan patients in 29 hospitals using Michigan Surgical Quality Collaborative clinical registry data from 2006 through 2010. Multivariable logistic regression and difference-in-differences analytic approaches were used to evaluate whether Keystone Surgery program implementation was associated with improved surgical outcomes following general surgery procedures, apart from existing temporal trends toward improved outcomes during the study period.
Risk-adjusted rates of superficial surgical site infection, wound complication, any complication, and 30-day mortality.
Implementation of Keystone Surgery in 14 participating centers was not associated with improvements in surgical outcomes during the study period. Adjusted rates of superficial surgical site infection (3.2% vs 3.2%, P=.91), wound complication (5.9% vs 6.5%, P=.30), any complication (12.4% vs 13.2%, P=.26), and 30-day mortality (2.1% vs 1.9%, P=.32) at participating hospitals were similar before and after implementation. Difference-in-differences analysis accounting for trends in 15 nonparticipating centers and sensitivity analysis excluding patients receiving surgery in the first 6 or 12 months after program implementation yielded similar results.
Implementation of a checklist-based quality improvement intervention did not affect rates of adverse surgical outcomes among patients undergoing general surgery in participating Michigan hospitals. Additional research is needed to understand why this program was not successful prior to further dissemination and implementation of this model to other populations.
以往关于基于检查表的质量改进干预措施的研究结果不一。
评估基于检查表的质量改进干预措施——基石手术（Keystone Surgery）——是否与全州范围内接受普通外科手术的大量患者的预后改善相关。
设计、设置和暴露因素：一项回顾性纵向研究利用2006年至2010年密歇根外科质量协作临床登记数据，检查了29家医院中64891名密歇根患者的手术结果。采用多变量逻辑回归和差异分析方法，评估除研究期间预后改善的现有时间趋势外，基石手术项目的实施是否与普通外科手术后手术结果的改善相关。
手术部位浅表感染、伤口并发症、任何并发症以及30天死亡率的风险调整率。
在14个参与中心实施基石手术与研究期间手术结果的改善无关。参与医院实施前后，手术部位浅表感染的调整率（3.2%对3.2%，P = 0.91）、伤口并发症（5.9%对6.5%，P = 0.30）、任何并发症（十二点四%对13.2%，P = 0.26）和30天死亡率（2.1%对1.9%，P = 0.32）相似。考虑15个非参与中心趋势的差异分析以及排除项目实施后头6或12个月接受手术患者的敏感性分析得出了相似结果。
在参与研究的密歇根医院中，基于检查表的质量改进干预措施的实施并未影响接受普通外科手术患者的不良手术结局发生率。在将该模式进一步推广和应用于其他人群之前，需要进行更多研究以了解该项目未成功的原因。
