Rudmik Luke, Xu Yuan, Alt Jeremiah A, Deconde Adam, Smith Timothy L, Schlosser Rodney J, Quan Hude, Soler Zachary M
Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
JAMA Otolaryngol Head Neck Surg. 2017 Sep 1;143(9):891-898. doi: 10.1001/jamaoto.2017.0752.
Several identified factors have raised questions concerning the quality of care for endoscopic sinus surgery (ESS), including the presence of large geographic variation in the rates and extent of surgery, poorly defined indications, and lack of ESS-specific quality metrics. Combined with the risk of major complications, ESS represents a high-value target for quality improvement.
To evaluate differences in surgeon-specific performance for ESS using a risk-adjusted, 5-year ESS revision rate as a quality metric.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective study used a population-based administrative database to study adults (≥18 years of age) with chronic rhinosinusitis (CRS) who underwent primary ESS in Alberta, Canada, between March 1, 2007, and March 1, 2010. The study period ended in 2015 to provide 5 years of follow-up.
Endoscopic sinus surgery for CRS.
Primary outcomes were the 5-year observed and risk-adjusted ESS revision rate. Logistic regression was used to develop a risk adjustment model for the primary outcome.
A total of 43 individual surgeons performed primary ESS in 2168 patients with CRS. Within 5 years after the primary ESS procedure, 239 patients underwent revision ESS, and the mean crude 5-year ESS revision rate was 10.6% (range, 2.4%-28.6%). After applying the risk adjustment model and 95% CI to each surgeon, 7 surgeons (16%) had lower-than-expected performance and 2 surgeons (5%) had higher-than-expected performance. Three variables had significant associations with surgeon-specific, 5-year ESS revision rates: presence of nasal polyps (odds ratio [OR], 2.07; 95% CI, 1.59-2.70), more annual systemic corticosteroid courses (OR, 1.33; 95% CI, 1.19-1.48), and concurrent septoplasty (OR, 0.70; 95% CI, 0.55-0.89).
Evaluating surgeon-specific performance for ESS may provide information to assist in quality improvement. Although most surgeons had comparable risk-adjusted, 5-year ESS revision rates, 16% of surgeons had lower-than-expected performance, indicating a potential to improve quality of care. Future studies are needed to evaluate more surgeon-specific variables and validate a risk adjustment model to provide appropriate feedback for quality improvement.
已确定的几个因素引发了关于鼻内镜鼻窦手术（ESS）护理质量的问题，包括手术率和范围存在较大的地域差异、适应证定义不明确以及缺乏ESS特异性质量指标。再加上重大并发症的风险，ESS是质量改进的一个高价值目标。
以风险调整后的5年ESS翻修率作为质量指标，评估ESS外科医生特定表现的差异。
设计、地点和参与者：这项回顾性研究使用了基于人群的行政数据库，研究2007年3月1日至2010年3月1日期间在加拿大艾伯塔省接受初次ESS的慢性鼻窦炎（CRS）成年患者（≥18岁）。研究期于2015年结束，以提供5年的随访。
针对CRS的鼻内镜鼻窦手术。
主要结局是5年观察到的和风险调整后的ESS翻修率。使用逻辑回归为主要结局建立风险调整模型。
共有43位个体外科医生为2168例CRS患者实施了初次ESS。在初次ESS手术后的5年内，239例患者接受了ESS翻修，5年ESS翻修率的平均粗率为10.6%（范围为2.4%-28.6%）。对每位外科医生应用风险调整模型和95%置信区间后，7位外科医生（16%）的表现低于预期，2位外科医生（5%）的表现高于预期。三个变量与外科医生特定的5年ESS翻修率有显著关联：鼻息肉的存在（比值比[OR]，2.07；95%置信区间，1.59-2.70）、每年全身使用皮质类固醇疗程更多（OR，1.33；95%置信区间，1.19-1.48）以及同期行鼻中隔成形术（OR，0.70；95%置信区间，0.55-0.89）。
评估ESS外科医生的特定表现可能为质量改进提供信息。尽管大多数外科医生的风险调整后5年ESS翻修率相当，但16%的外科医生表现低于预期，这表明在护理质量方面有改进的潜力。未来需要开展研究以评估更多外科医生特定的变量，并验证风险调整模型，以便为质量改进提供适当反馈。
