Iobst Christopher A, Stillwagon Matthew, Ryan Deidre, Shirley Eric, Frick Steven L
*Nationwide Childrens Hospital, Columbus, OH §Nemours Children's Specialty Care, Jacksonville, FL †Department of Orthopedic Surgery, Chapel Hill, NC ‡Children's Hospital of Los Angeles, Los Angeles ¶Stanford University School of Medicine, Palo Alto, CA.
J Pediatr Orthop. 2017 Jul/Aug;37(5):e303-e307. doi: 10.1097/BPO.0000000000000992.
Recently, there has been an emphasis on improving quality, safety, and value in the delivery of health care in the United States. The American Board of Orthopedic Surgery (ABOS) has developed a performance improvement questionnaire (PIQ) for orthopaedic surgeons managing pediatric supracondylar humerus fracture (PSCHF). Using the supracondylar PIQ as a guide, this study evaluates the process of measuring the outcomes and variations in care to PSCHF patients among pediatric orthopaedic surgeons.
An 88-question survey incorporating the ABOS PIQ was administered to 35 pediatric orthopaedic surgeons at 3 institutions. A retrospective chart review of patients who received operative management of a PSCHF during 2013 was performed. Each of the 17 eligible surgeons supplied 5 patients for a total of 85 patients. Medical records and radiographic imaging were reviewed using the ABOS PIQ data collection sheet. This data collection sheet encompasses the preoperative assessment, intraoperative treatment and assessment, and clinical and radiographic outcomes of patients with PSCHF.
A total of 35 surgeons from 6 hospitals completed the online PSCHF survey. Uniform consensus among all 35 surgeons was identified in 21/79 of the questions (27%). Consensus among surgeons within a hospital group but not with surgeons from the other groups was identified in 39/79 (49%) of the questions. No consensus among the surveyed surgeons could be identified in 19/79 (24%) of the questions. For the 85 PSCHF patients the average age was 6 years, and 37% of fractures were type II, 57% of fractures were type III, and there was 1 flexion type. Ninety percent of the patients received a preoperative dose of antibiotics and the postoperative immobilization placed in the operating room was changed in the clinic before pin removal in 58% of the cases. Pins were removed at 3 weeks in 60%, 4 weeks in 30%, 5 weeks in 7%, and after 5 weeks in 3% of the patients and no malunions occurred. Pin tract infection occurred in 2 patients (2.4%). The procedure time ranged from 13 to 171 minutes, with a median time of 37 minutes. Total anesthesia time ranged from 32 to 233 minutes, with a median of 72 minutes. The number of outpatient follow-up visits ranged from 2 to 7 visits, with a median of 3 visits. The number of postoperative radiographs obtained ranged from 1 to 14, with a median of 3 studies. Four patients (5%) returned to the operating room for a repeat surgery.
The survey responses from the surgeons at 6 different hospitals demonstrate that there is still considerable variation in care among surgeons, even for such a routine injury. Our chart review also revealed substantial variation in care with subsequent quality and cost-implications. The variations in operating room time, anesthesiology time, number of postoperative visits, number of radiographs ordered, and the initial intraoperative immobilization, all point to opportunities for standardization and lowering of costs.
Level IV.
最近，美国医疗保健服务领域一直强调提高质量、安全性和价值。美国骨科手术委员会（ABOS）已为管理小儿肱骨髁上骨折（PSCHF）的骨科医生制定了一份绩效改进问卷（PIQ）。本研究以髁上PIQ为指导，评估了小儿骨科医生对PSCHF患者护理结果的测量过程及护理差异。
向3家机构的35名小儿骨科医生发放了一份包含ABOS PIQ的88个问题的调查问卷。对2013年接受PSCHF手术治疗的患者进行回顾性病历审查。17名符合条件的外科医生每人提供5名患者，共85名患者。使用ABOS PIQ数据收集表对病历和影像学资料进行审查。该数据收集表涵盖了PSCHF患者的术前评估、术中治疗和评估以及临床和影像学结果。
来自6家医院的35名外科医生完成了在线PSCHF调查。在79个问题中的21个（27%）问题上，35名外科医生达成了一致意见。在79个问题中的39个（49%）问题上，医院组内的外科医生达成了一致意见，但与其他组的外科医生未达成一致。在79个问题中的19个（24%）问题上，接受调查的外科医生未达成一致意见。85例PSCHF患者的平均年龄为6岁，37%的骨折为II型，57%的骨折为III型，有1例屈曲型骨折。90%的患者术前接受了抗生素治疗，58%的病例在手术室进行的术后固定在门诊拔除钢针前发生了改变。60%的患者在3周时拔除钢针，30%的患者在4周时拔除，7%的患者在5周时拔除，3%的患者在5周后拔除，未发生骨不连。2例患者（2.4%）发生了针道感染。手术时间为13至171分钟，中位时间为37分钟。总麻醉时间为32至233分钟，中位时间为72分钟。门诊随访次数为2至7次，中位次数为3次。术后获得的X线片数量为1至14张，中位数量为3次。4例患者（5%）返回手术室进行再次手术。
来自6家不同医院的外科医生的调查回复表明，即使对于这样一种常规损伤，外科医生之间的护理差异仍然很大。我们的病历审查还揭示了护理方面的显著差异以及随之而来的质量和成本问题。手术室时间、麻醉时间、术后访视次数、X线片数量以及初始术中固定方面的差异，都表明了标准化和降低成本的机会。
IV级。
