Udyavar N Rhea, Salim Ali, Havens Joaquim M, Cooper Zara, Cornwell Edward E, Lipsitz Stuart R, Scott John W, Haider Adil H
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
J Surg Res. 2018 Sep;229:51-57. doi: 10.1016/j.jss.2018.02.051. Epub 2018 Apr 16.
Benchmarking of mortality outcomes across the country has revealed major differences in survival based on the trauma center at which a patient receives care. The role of the individual surgeon in determining trauma outcomes is unknown. Most believe that differences in outcomes are primarily driven by system- and process-based variations. Our objective was to determine if variation in individual surgeon outcomes could help explain difference in survival after trauma.
Analysis of trauma patients in the Florida State Inpatient Database from 2010 to 2014. The presence of unique physician identifiers, in addition to hospital identifiers, rendered this data set ideal for performance of multilevel analysis. The amount of the variation attributable to surgeon-level variation was calculated using multilevel random-effects models controlling for patient clinical factors (such as injury severity and comorbidities/age) and hospital-level factors, such as case mix and bed size.
There were 31 hospitals, 175 surgeons, and 65,706 admissions. The overall mortality rate was 5.6%. The average mortality rate across surgeons ranged from 0% to 17.4% (mean 0.4%, standard deviation 1.85). At the individual surgeon level, when controlling for clinical and hospital-level factors, 9% of this variation was attributable solely to the surgeon.
At the state level, we found that differences in outcomes among trauma centers are impacted by individual surgeon-level variation. Implementation of protocolized, system-based trauma care is useful for improving the overall quality of care for injured patients but does not entirely negate surgeon-specific variations in management.
全国范围内死亡率结果的基准研究表明，患者接受治疗的创伤中心不同，其生存率存在重大差异。个体外科医生在决定创伤治疗结果中所起的作用尚不清楚。大多数人认为，结果差异主要由基于系统和流程的差异驱动。我们的目的是确定个体外科医生治疗结果的差异是否有助于解释创伤后生存率的差异。
分析2010年至2014年佛罗里达州住院患者数据库中的创伤患者。除了医院标识符外，独特的医生标识符的存在使该数据集非常适合进行多层次分析。使用控制患者临床因素（如损伤严重程度和合并症/年龄）和医院层面因素（如病例组合和床位规模）的多层次随机效应模型，计算归因于外科医生层面差异的变异量。
共有31家医院、175名外科医生和65706例入院病例。总体死亡率为5.6%。外科医生的平均死亡率在0%至17.4%之间（平均0.4%，标准差1.85）。在个体外科医生层面，在控制临床和医院层面因素时，这种差异的9%仅归因于外科医生。
在州一级，我们发现创伤中心之间的结果差异受到个体外科医生层面差异的影响。实施基于协议和系统的创伤护理有助于提高受伤患者的整体护理质量，但并不能完全消除外科医生在管理上的个体差异。
