Calderwood Michael S, Kleinman Ken, Huang Susan S, Murphy Michael V, Yokoe Deborah S, Platt Richard
*Division of Infectious Diseases, Brigham and Women's Hospital †Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston ‡Department of Biostatistics and Epidemiology, University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, MA §Division of Infectious Diseases, University of California Irvine School of Medicine, Orange, CA.
Med Care. 2017 Jan;55(1):79-85. doi: 10.1097/MLR.0000000000000620.
Surgical site infection (SSI) rates are publicly reported as quality metrics and increasingly used to determine financial reimbursement.
To evaluate the volume-outcome relationship as well as the year-to-year stability of performance rankings following coronary artery bypass graft (CABG) surgery and hip arthroplasty.
We performed a retrospective cohort study of Medicare beneficiaries who underwent CABG surgery or hip arthroplasty at US hospitals from 2005 to 2011, with outcomes analyzed through March 2012. Nationally validated claims-based surveillance methods were used to assess for SSI within 90 days of surgery. The relationship between procedure volume and SSI rate was assessed using logistic regression and generalized additive modeling. Year-to-year stability of SSI rates was evaluated using logistic regression to assess hospitals' movement in and out of performance rankings linked to financial penalties.
Case-mix adjusted SSI risk based on claims was highest in hospitals performing <50 CABG/year and <200 hip arthroplasty/year compared with hospitals performing ≥200 procedures/year. At that same time, hospitals in the worst quartile in a given year based on claims had a low probability of remaining in that quartile the following year. This probability increased with volume, and when using 2 years' experience, but the highest probabilities were only 0.59 for CABG (95% confidence interval, 0.52-0.66) and 0.48 for hip arthroplasty (95% confidence interval, 0.42-0.55).
Aggregate SSI risk is highest in hospitals with low annual procedure volumes, yet these hospitals are currently excluded from quality reporting. Even for higher volume hospitals, year-to-year random variation makes past experience an unreliable estimator of current performance.
手术部位感染（SSI）率作为质量指标被公开报告，并越来越多地用于确定财务报销。
评估冠状动脉搭桥术（CABG）和髋关节置换术后的手术量-结局关系以及绩效排名的逐年稳定性。
我们对2005年至2011年在美国医院接受CABG手术或髋关节置换术的医疗保险受益人群进行了一项回顾性队列研究，结局分析至2012年3月。采用全国验证的基于索赔的监测方法评估手术后90天内的SSI。使用逻辑回归和广义相加模型评估手术量与SSI率之间的关系。使用逻辑回归评估SSI率的逐年稳定性，以评估医院在与财务处罚相关的绩效排名中的进出情况。
与每年进行≥200例手术的医院相比，每年进行<50例CABG手术和<200例髋关节置换术的医院基于索赔的病例组合调整后的SSI风险最高。同时，在给定年份中基于索赔处于最差四分位数的医院，次年仍处于该四分位数的概率较低。该概率随手术量增加，使用两年经验时概率增加，但CABG的最高概率仅为0.59（95%置信区间，0.52 - 0.66），髋关节置换术为0.48（95%置信区间，0.42 - 0.55）。
年手术量低的医院总体SSI风险最高，但这些医院目前被排除在质量报告之外。即使对于手术量较高的医院，逐年的随机变化也使得过去的经验成为当前绩效的不可靠估计。
