Division of Cardiology, Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan.
Division of Critical Care Medicine, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California.
Ann Thorac Surg. 2018 Feb;105(2):615-621. doi: 10.1016/j.athoracsur.2017.06.027. Epub 2017 Oct 5.
Few metrics exist to assess quality of care at pediatric cardiac surgical programs, limiting opportunities for benchmarking and quality improvement. Postoperative duration of mechanical ventilation (POMV) may be an important quality metric because of its association with complications and resource utilization. In this study we modelled case-mix-adjusted POMV duration and explored hospital performance across POMV metrics.
This study used the Pediatric Cardiac Critical Care Consortium clinical registry to analyze 4,739 hospitalizations from 15 hospitals (October 2013 to August 2015). All patients admitted to pediatric cardiac intensive care units after an index cardiac operation were included. We fitted a model to predict duration of POMV accounting for patient characteristics. Robust estimates of SEs were obtained using bootstrap resampling. We created performance metrics based on observed-to-expected (O/E) POMV to compare hospitals.
Overall, 3,108 patients (65.6%) received POMV; the remainder were extubated intraoperatively. Our model was well calibrated across groups; neonatal age had the largest effect on predicted POMV. These comparisons suggested clinically and statistically important variation in POMV duration across centers with a threefold difference observed in O/E ratios (0.6 to 1.7). We identified 1 hospital with better-than-expected and 3 hospitals with worse-than-expected performance (p < 0.05) based on the O/E ratio.
We developed a novel case-mix-adjusted model to predict POMV duration after congenital heart operations. We report variation across hospitals on metrics of O/E duration of POMV that may be suitable for benchmarking quality of care. Identifying high-performing centers and practices that safely limit the duration of POMV could stimulate quality improvement efforts.
评估儿科心脏外科项目护理质量的指标很少，限制了基准测试和质量改进的机会。术后机械通气时间（POMV）可能是一个重要的质量指标，因为它与并发症和资源利用有关。在这项研究中，我们建立了病例组合调整后的 POMV 持续时间模型，并探讨了 POMV 指标的医院绩效。
本研究使用儿科心脏危重病护理联盟临床登记处分析了 15 家医院（2013 年 10 月至 2015 年 8 月）的 4739 例住院患者。所有接受心脏手术后入住儿科心脏重症监护病房的患者均纳入本研究。我们建立了一个预测 POMV 持续时间的模型，该模型考虑了患者的特征。使用自举重采样获得了稳健的 SE 估计值。我们根据观察到的与预期的（O/E）POMV 创建了绩效指标，以比较医院。
总体而言，3108 例患者（65.6%）接受了 POMV；其余患者在术中拔管。我们的模型在各亚组中均具有良好的校准性；新生儿年龄对预测 POMV 的影响最大。这些比较表明，中心之间的 POMV 持续时间存在临床和统计学上的显著差异，O/E 比值差异高达三倍（0.6 至 1.7）。我们根据 O/E 比值发现，1 家医院的表现优于预期，3 家医院的表现差于预期（p < 0.05）。
我们开发了一种新的病例组合调整模型来预测先天性心脏病手术后的 POMV 持续时间。我们报告了医院之间在 POMV 持续时间的 O/E 度量上的差异，这些差异可能适合用于基准测试护理质量。确定表现良好的中心和安全限制 POMV 持续时间的实践可能会刺激质量改进工作。
