Schrem Harald, Volz Sophia, Koch Hans-Friedrich, Gwiasda Jill, Kürsch Priscila, Goldis Alon, Pöhnert Daniel, Winny Markus, Klempnauer Jürgen, Kaltenborn Alexander
Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany.
Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany.
Langenbecks Arch Surg. 2018 Feb;403(1):61-71. doi: 10.1007/s00423-017-1612-7. Epub 2017 Sep 9.
This study investigated the utility of retrospective two one-sided cumulative sum (CUSUM) charts combined with multivariable regression analysis in liver transplantation for transplant center benchmarking.
One thousand seven hundred and forty-nine consecutive adult primary liver transplants (January 1, 1983 to December 31, 2012) were analyzed retrospectively with two one-sided CUSUM chart analysis of 90-day mortality.
Three eras and two subseries in latest era 3 were identified due to graphically delineated relevant shifts in mean 90-day mortality. Delineation of eras 1, 2, and 3 coincided with relevant changes in allocation policies. CUSUM analysis detected a resurgence of higher mean 90-day mortality in era 3 after results had improved continuously over 25 years. In era 3, two subseries were identified with improving mean 90-day mortality rates from 15.4% in subseries 1 to 8.9% in the following subseries 2. The quantitative influence of independent risk factors on 90-day mortality differed markedly between all identified eras and subseries as assessed with multivariable regression analysis deployed on era-specific subcohorts.
The assessed methodology is able to identify meaningful center-specific eras and subseries of liver transplantation with striking alterations of the significance and weight of outcome drivers for post-transplant 90-day mortality over time. This warrants the introduction of prospective risk-adjusted two one-sided CUSUM chart analysis into quality management in liver transplantation in Germany with the goal to obtain alarm signals as early as possible.
本研究探讨回顾性双侧累积和（CUSUM）图表结合多变量回归分析在肝移植中用于移植中心基准评估的效用。
对1983年1月1日至2012年12月31日期间连续进行的1749例成人原发性肝移植进行回顾性分析，采用双侧CUSUM图表分析90天死亡率。
由于90天平均死亡率在图形上出现了明显的相关变化，确定了三个时期以及最新时期3中的两个子系列。时期1、2和3的划分与分配政策的相关变化一致。CUSUM分析发现，在结果持续改善25年后，时期3的90天平均死亡率再次上升。在时期3中，确定了两个子系列，90天平均死亡率从子系列1中的15.4%降至随后子系列2中的8.9%。通过对特定时期亚队列进行多变量回归分析评估，所有确定的时期和子系列中，独立危险因素对90天死亡率的定量影响存在显著差异。
所评估的方法能够识别肝移植中有意义的特定中心时期和子系列，随着时间推移，移植后90天死亡率的结果驱动因素的重要性和权重发生了显著变化。这使得在德国将前瞻性风险调整后的双侧CUSUM图表分析引入肝移植质量管理成为必要，目的是尽早获得警报信号。
