Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; Department of Surgery, University of Chicago Medical Center, Chicago, IL; Surgical Outcomes and Quality Improvement, Department of Surgery and Northwestern Institute for Comparative Effectiveness Research in Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL.
Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; Department of Surgery, University of Chicago Medical Center, Chicago, IL.
J Am Coll Surg. 2016 May;222(5):790-797.e1. doi: 10.1016/j.jamcollsurg.2016.01.057. Epub 2016 Feb 13.
Surgical quality programs, such as the American College of Surgeons NSQIP, provide reports based on specialty or procedure, with patients aggregated together. It is unknown whether hospital performance differs by patient subgroup (eg cancer vs noncancer patients), masking opportunities for improvement. Our objectives were to determine whether performance differs within a given hospital for 6 contrasting patient subgroups and to identify the percentage of hospitals with greater than chance differences in performance.
Using the American College of Surgeons NSQIP data, adults undergoing lung resection, esophagectomy, hepatectomy, pancreatectomy, colectomy, and proctectomy (2005 through 2012) were divided into 6 contrasting subgroups (elderly vs nonelderly, white vs nonwhite, obese vs nonobese, renal insufficiency vs normal renal function, cancer vs noncancer, emergency vs nonemergency). The main end point was serious morbidity or mortality. Observed to expected ratios were constructed using hierarchical models and compared using paired t-tests (eg observed to expected for cancer cases compared with noncancer). Variation in performance differences was assessed using a randomization test and z-tests for proportions.
From 433 hospitals, 221,518 patients were included. Overall quality differed for elderly vs nonelderly, renal insufficiency vs normal renal function patients, cancer vs noncancer, and emergency vs nonemergency (p < 0.05). Variation in within-hospital performance differences exceeded chance expectations for renal insufficiency vs normal renal function in 31.1% of hospitals, cancer vs noncancer in 40.8%, and emergency vs nonemergency patients in 55.4% (p < 0.001).
Hospital performance within a given hospital varies by patient subgroup. Quality programs can consider separate reports for these subgroups to identify opportunities for quality improvement.
外科质量计划，如美国外科医师学院 NSQIP，提供基于专业或手术的报告，将患者汇总在一起。尚不清楚医院的表现是否因患者亚组（如癌症与非癌症患者）而异，从而掩盖了改进的机会。我们的目的是确定在给定的医院内，对于 6 个具有对比性的患者亚组，其绩效是否存在差异，并确定绩效存在差异的医院比例是否大于偶然差异。
使用美国外科医师学院 NSQIP 数据，将 2005 年至 2012 年间接受肺切除术、食管切除术、肝切除术、胰腺切除术、结肠切除术和直肠切除术的成年人分为 6 个具有对比性的亚组（老年与非老年、白人与非白人、肥胖与非肥胖、肾功能不全与正常肾功能、癌症与非癌症、急诊与非急诊）。主要终点是严重发病率或死亡率。使用分层模型构建观察到的与预期的比值，并使用配对 t 检验进行比较（例如，与非癌症病例相比，癌症病例的观察到的与预期的比值）。使用随机化检验和比例 z 检验评估绩效差异的变化。
从 433 家医院中，共纳入 221518 名患者。老年与非老年、肾功能不全与正常肾功能、癌症与非癌症以及急诊与非急诊患者的整体质量存在差异（p<0.05）。在 31.1%的医院中，肾功能不全与正常肾功能患者的医院内绩效差异变化超过了随机预期，在 40.8%的医院中，癌症与非癌症患者的绩效差异变化超过了随机预期，在 55.4%的医院中，急诊与非急诊患者的绩效差异变化超过了随机预期（p<0.001）。
在给定的医院内，医院的绩效因患者亚组而异。质量计划可以考虑为这些亚组单独报告，以确定质量改进的机会。
