手术后继发性并发症的医院层面差异。
Hospital-level Variation in Secondary Complications After Surgery.
作者信息
Wakeam Elliot, Hyder Joseph A, Lipsitz Stuart R, Cohen Mark E, Orgill Dennis P, Zinner Michael J, Ko Cliff Y, Hall Bruce L, Finlayson Samuel R G
机构信息
*Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA †Department of Surgery, University of Toronto, Toronto, Canada ‡Department of Anesthesiology, Mayo Clinic, Rochester, MN §Division of Research/Optimal Patient Care, American College of Surgeons, Chicago, IL ||Department of Surgery, University of California-Los Angeles, Los Angeles, CA ¶Washington University in Saint Louis, Department of Surgery (School of Medicine), Olin Business School, and Center for Health Policy; BJC Healthcare St Louis, MO **Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT.
出版信息
Ann Surg. 2016 Mar;263(3):493-501. doi: 10.1097/SLA.0000000000001227.
OBJECTIVES
To assess whether hospital rates of secondary complications could serve as a performance benchmark and examine associations with mortality.
BACKGROUND
Failure to rescue (death after postoperative complication) is a challenging target for quality improvement. Secondary complications (complications after a first or "index" complication) are intermediate outcomes in the rescue process that may provide specific improvement targets and give us insight into how rescue fails.
METHODS
We used American College of Surgeons' National Surgical Quality Improvement Program data (2008-2012) to define hospital rates of secondary complications after 5 common index complications: pneumonia, surgical site infection (SSI), urinary tract infection, transfusion/bleed events, and acute myocardial infarction (MI). Hospitals were divided into quintiles on the basis of risk- and reliability-adjusted rates of secondary complications, and these rates were compared along with mortality.
RESULTS
A total of 524,860 patients were identified undergoing one of the 62 elective, inpatient operations. After index pneumonia, secondary complication rates varied from 57.99% in the highest quintile to 22.93% in the lowest [adjusted odds ratio (OR), 4.64; confidence interval (CI), 3.95-5.45). Wide variation was seen after index SSI (58.98% vs 14.81%; OR, 8.53; CI, 7.41-9.83), urinary tract infection (38.41% vs 8.60%; OR, 7.81; CI, 6.48-9.40), transfusion/bleeding events (27.14% vs 12.88%; OR, 2.54; CI, 2.31-2.81), and acute MI (64.45% vs 23.86%, OR, 6.87; CI, 5.20-9.07). Hospitals in the highest quintile had significantly greater mortality after index pneumonia (10.41% vs 6.20%; OR, 2.17; CI, 1.6-2.94), index MI (18.25% vs 9.65%; OR, 2.67; CI, 1.80-3.94), and index SSI (2.75% vs 0.82%; OR, 3.93; CI, 2.26-6.81).
CONCLUSIONS
Hospital-level rates of secondary complications (failure to arrest complications) vary widely, are associated with mortality, and may be useful for quality improvement and benchmarking.
目的
评估医院二级并发症发生率是否可作为一项绩效基准，并研究其与死亡率的关联。
背景
未能成功救治（术后并发症后死亡）是质量改进面临的一项具有挑战性的目标。二级并发症（首次或“索引”并发症后的并发症）是救治过程中的中间结果，可能提供具体的改进目标，并让我们深入了解救治失败的原因。
方法
我们使用美国外科医师学会国家外科质量改进计划的数据（2008 - 2012年）来确定5种常见索引并发症（肺炎、手术部位感染、尿路感染、输血/出血事件和急性心肌梗死）后的医院二级并发症发生率。根据风险和可靠性调整后的二级并发症发生率将医院分为五等分，并将这些发生率与死亡率进行比较。
结果
共识别出524,860例接受62种择期住院手术之一的患者。索引肺炎后，二级并发症发生率从最高五等分的57.99%到最低五等分的22.93%不等[调整优势比（OR）为4.64；置信区间（CI）为3.95 - 5.45]。索引手术部位感染（58.98%对14.81%；OR为8.53；CI为7.41 - 9.83）、尿路感染（38.41%对8.60%；OR为7.81；CI为6.48 - 9.40）、输血/出血事件（27.14%对12.88%；OR为2.54；CI为2.31 - 2.81）和急性心肌梗死（64.45%对23.86%，OR为6.87；CI为5.20 - 9.07）后也观察到广泛差异。最高五等分的医院在索引肺炎（10.41%对6.20%；OR为2.17；CI为1.6 - 2.94）、索引心肌梗死（18.25%对9.65%；OR为2.67；CI为1.80 - 3.94）和索引手术部位感染（2.75%对0.82%；OR为3.93；CI为2.26 - 6.81）后的死亡率显著更高。
结论
医院层面的二级并发症发生率（未能阻止并发症）差异很大，与死亡率相关，可能有助于质量改进和基准设定。
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