Veterans Health Administration, National Surgery Office, Glendale, Colorado.
Veterans Health Administration, National Surgery Office, Washington DC3Department of Surgery, The George Washington University, Washington DC.
JAMA Surg. 2016 May 1;151(5):417-22. doi: 10.1001/jamasurg.2015.4882.
For more than 2 decades, the Veterans Health Administration (VHA) has relied on risk-adjusted, postoperative, 30-day mortality data as a measure of surgical quality of care. Recently, the use of 30-day mortality data has been criticized based on a theory that health care professionals manage patient care to meet the metric and that other outcome metrics are available.
To determine whether postoperative mortality data identify a delay in care to meet a 30-day mortality metric and to evaluate whether 30-day mortality risk score groups stratify survival patterns up to 365 days after surgery in surgical procedures assessed by the Veterans Affairs Surgical Quality Improvement Program (VASQIP).
DESIGN, SETTING, AND PARTICIPANTS: Patients undergoing VASQIP-assessed surgical procedures within the VHA from October 1, 2011, to September 30, 2013, were evaluated. Data on 365-day survival follow-up of 212 733 surgical cases using VHA Vital Status and admission records were obtained with 10 947 mortality events. Data analysis was conducted from September 3, 2014, to November 9, 2015.
Survival up to 365 days after surgery for the overall cohort divided into 10 equal groups (deciles).
There were 10 947 mortality events identified in a cohort of 212 733 surgical patients. The mean probability of death was 1.03% (95% CI, 1.01%-1.04%). Risk estimate groups in the 212 733 surgical cases analyzed showed significantly different postoperative survival, with consistency beyond the time frame for which they were developed. The lowest risk decile had the highest 365-day survival probability (99.74%; 95% CI, 99.66%-99.80%); the highest risk decile had the lowest 365-day survival probability (72.04%; 95% CI, 71.43%-72.64%). The 9 lowest risk deciles had linear survival curves from 0 to 365 postoperative days, with the highest risk decile having early survival risk and becoming more linear after the first 180 days. Survival curves between 25 and 35 days were consistent for all risk deciles and showed no evidence that mortality rates were affected in the immediate period beyond day 30. The setting of mortality varied by postoperative day ranges, with index hospitalization events declining and deaths outside of the hospital increasing up to 365 days.
Deciles of 30-day mortality estimates are associated with significantly different survival outcomes at 365 days even after removing patients who died within the first 30 postoperative days. No evidence of delays in patient care and treatment to meet a 30-day metric were identified. These findings reinforce the usefulness of 30-day mortality risk stratification as a surrogate for long-term outcomes.
20 多年来，退伍军人事务部（VA）一直依赖风险调整后、术后 30 天死亡率数据作为手术护理质量的衡量标准。最近，有人批评使用 30 天死亡率数据，其理论依据是医疗保健专业人员为了达到该指标而管理患者的护理，并且有其他的结果指标可用。
确定术后死亡率数据是否可以识别出延迟护理以满足 30 天死亡率指标，以及评估 30 天死亡率风险评分组是否可以在退伍军人事务部手术质量改进计划（VASQIP）评估的手术程序中分层 365 天后的生存模式。
设计、地点和参与者：对 2011 年 10 月 1 日至 2013 年 9 月 30 日期间在退伍军人事务部接受 VASQIP 评估的手术程序的患者进行了评估。使用退伍军人事务部生命状况和入院记录获得了 212733 例手术病例的 365 天生存随访数据，共发生了 10947 例死亡事件。数据分析于 2014 年 9 月 3 日至 2015 年 11 月 9 日进行。
对整个队列（10 等分）进行了 365 天手术后的生存分析。
在 212733 例手术患者队列中确定了 10947 例死亡事件。平均死亡概率为 1.03%（95%CI，1.01%-1.04%）。分析的 212733 例手术病例的风险估计组显示出明显不同的术后生存情况，这种一致性超出了它们开发的时间框架。分析的 212733 例手术病例的风险估计组显示出明显不同的术后生存情况，这种一致性超出了它们开发的时间框架。风险最低的十分位数具有最高的 365 天生存率（99.74%；95%CI，99.66%-99.80%）；风险最高的十分位数具有最低的 365 天生存率（72.04%；95%CI，71.43%-72.64%）。9 个最低风险十分位数的术后 0 至 365 天生存曲线呈线性，而最高风险十分位数的早期生存风险较高，在术后第 180 天之后变得更加线性。所有风险十分位数的 25 至 35 天生存曲线一致，没有证据表明在术后 30 天的即时期间死亡率受到影响。死亡率的设定因术后天数范围而异，指数住院事件下降，而院外死亡事件增加至 365 天。
即使在去除术后 30 天内死亡的患者后，30 天死亡率估计的十分位数仍与 365 天的显著不同的生存结果相关。没有证据表明存在为了达到 30 天指标而延迟患者护理和治疗的情况。这些发现强化了 30 天死亡率风险分层作为长期结果替代指标的有用性。
