Voorn Veronique M A, Marang-van de Mheen Perla J, van der Hout Anja, So-Osman Cynthia, van den Akker-van Marle M Elske, Koopman-van Gemert Ankie W M M, Dahan Albert, Vliet Vlieland Thea P M, Nelissen Rob G H H, van Bodegom-Vos Leti
Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands.
Department of Transfusion Medicine, Sanquin Blood Supply, Leiden, The Netherlands.
BMJ Open. 2017 Jul 20;7(7):e014143. doi: 10.1136/bmjopen-2016-014143.
Outcomes in total hip and knee arthroplasty (THA and TKA), such as allogeneic transfusions or extended length of stay (LoS), can be used to compare the performance of hospitals. However, there is much variation in these outcomes. This study aims to rank hospitals and to assess hospital differences of two outcomes in THA and TKA: allogeneic transfusions and extended LoS, and to additionally identify factors associated with these differences.
Cross-sectional medical record review study.
Data were gathered in 23 Dutch hospitals.
1163 THA and 986 TKA patient admissions.
Hospitals were ranked based on their observed/expected (O/E) ratios regarding allogeneic transfusion and extended LoS percentages (extended LoS was defined by postoperative stay >4 days). To assess the reliability of these rankings, we calculated which percentage of the existing variation was based on differences between hospitals as compared with random variation (after adjustment for variation in patient characteristics). Associations between hospital-specific factors and O/E ratios were used to explore potential sources of differences.
The variation in O/E ratios between hospitals ranged from 0 to 4.4 for allogeneic transfusion, and from 0.08 to 2.7 for extended LoS. Variation in transfusion could in 21% be explained by hospital differences in THA and 34% in TKA. For extended LoS this was 71% in THA and 78% in TKA. Better performance (low O/E ratios) in transfusion was associated with more frequent tranexamic acid (TXA) use in TKA (R=-0.43, p=0.04). Better performance in extended LoS was associated with more frequent TXA use in THA (R=-0.45, p=0.03) and TKA (R=-0.65, p<0.001) and local infiltration analgesia (LIA) in TKA (R=-0.60, p=0.002).
Ranking hospitals based on allogeneic transfusion is unreliable due to small percentages of variation explained by hospital differences. Ranking based on extended LoS is more reliable. Hospitals using TXA and LIA have relatively fewer patients with transfusions and extended LoS.
全髋关节置换术（THA）和全膝关节置换术（TKA）的一些结果，如同种异体输血或住院时间延长，可用于比较医院的医疗表现。然而，这些结果存在很大差异。本研究旨在对医院进行排名，评估THA和TKA中同种异体输血和住院时间延长这两个结果的医院差异，并进一步确定与这些差异相关的因素。
横断面病历回顾研究。
数据收集于23家荷兰医院。
1163例THA患者入院病例和986例TKA患者入院病例。
根据同种异体输血的观察/预期（O/E）比值和住院时间延长百分比（住院时间延长定义为术后住院时间>4天）对医院进行排名。为评估这些排名的可靠性，我们计算了现有差异中基于医院间差异而非随机差异（在调整患者特征差异后）的百分比。利用医院特定因素与O/E比值之间的关联来探索差异的潜在来源。
医院间同种异体输血的O/E比值差异范围为0至4.4，住院时间延长的差异范围为0.08至2.7。THA中输血差异的21%可由医院差异解释，TKA中为34%。对于住院时间延长，THA中为71%，TKA中为78%。输血方面表现较好（O/E比值低）与TKA中更频繁使用氨甲环酸（TXA）相关（R=-0.43，p=0.04）。住院时间延长方面表现较好与THA（R=-0.45，p=0.03）和TKA（R=-0.65，p<0.001）中更频繁使用TXA以及TKA中局部浸润麻醉（LIA）相关（R=-0.60，p=0.002）。
由于医院差异所解释的差异百分比小，基于同种异体输血对医院进行排名不可靠。基于住院时间延长进行排名更可靠。使用TXA和LIA的医院中输血和住院时间延长的患者相对较少。
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