Sheetz Kyle H, Dimick Justin B, Ghaferi Amir A
Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.
Ann Surg. 2016 Apr;263(4):692-7. doi: 10.1097/SLA.0000000000001414.
To determine the effect of hospital characteristics on failure to rescue after high-risk surgery in Medicare beneficiaries.
Reducing failure to rescue events is a common quality target for US hospitals. Little is known about which hospital characteristics influence this phenomenon and more importantly by how much.
We identified 1,945,802 Medicare beneficiaries undergoing 1 of six high-risk general or vascular operations between 2007 and 2010. Using multilevel mixed-effects logistic regression modeling, we evaluated how failure to rescue rates were influenced by specific hospital characteristics previously associated with postsurgical outcomes. We used variance partitioning to determine the relative influence of patient and hospital characteristics on the between-hospital variability in failure to rescue rates.
Failure to rescue rates varied up to 11-fold between very high and very low mortality hospitals. Comparing the highest and lowest mortality hospitals, we observed that teaching status (range: odds ratio [OR] 1.08-1.54), high hospital technology (range: OR 1.08-1.58), increasing nurse-to-patient ratio (range: OR 1.02-1.14), and presence of >20 intensive care unit (ICU) beds (range: OR 1.09-1.62) significantly influenced failure to rescue rates for all procedures. When taken together, hospital and patient characteristics accounted for 12% (lower extremity revascularization) to 57% (esophagectomy) of the observed variation in failure to rescue rates across hospitals.
Although several hospital characteristics are associated with lower failure to rescue rates, these macrosystem factors explain a small proportion of the variability between hospitals. This suggests that microsystem characteristics, such as hospital culture and safety climate, may play a larger role in improving a hospital's ability to manage postoperative complications.
确定医院特征对医疗保险受益人的高风险手术后抢救失败的影响。
减少抢救失败事件是美国医院常见的质量目标。对于哪些医院特征会影响这一现象，以及更重要的是影响程度如何，人们知之甚少。
我们确定了2007年至2010年间接受六种高风险普通或血管手术之一的1,945,802名医疗保险受益人。使用多水平混合效应逻辑回归模型，我们评估了抢救失败率如何受到先前与术后结果相关的特定医院特征的影响。我们使用方差分解来确定患者和医院特征对医院间抢救失败率差异的相对影响。
在死亡率非常高和非常低的医院之间，抢救失败率相差高达11倍。比较死亡率最高和最低的医院，我们观察到教学状态（范围：比值比[OR]1.08 - 1.54）、医院技术水平高（范围：OR 1.08 - 1.58）、护士与患者比例增加（范围：OR 1.02 - 1.14）以及重症监护病房（ICU）床位>20张（范围：OR 1.09 - 1.62）对所有手术的抢救失败率有显著影响。综合来看，医院和患者特征占各医院间观察到的抢救失败率差异的12%（下肢血管重建术）至57%（食管切除术）。
虽然一些医院特征与较低的抢救失败率相关，但这些宏观系统因素仅解释了医院间差异的一小部分。这表明微观系统特征，如医院文化和安全氛围，可能在提高医院管理术后并发症的能力方面发挥更大作用。
