J. K. Wong, T. E. Kim, S. C. Mudumbai, S. K. Howard, E. R. Mariano, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA J. K. Wong, T. E. Kim, S. C. Mudumbai, S. K. Howard, R. King, E. R. Mariano, Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA S. G. Memtsoudis, Departments of Anesthesiology and Public Health, Weill Cornell Medical College, New York, NY, USA S. G. Memtsoudis, Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA N. J. Giori, Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA N. J. Giori, Orthopaedic Surgery Section, Surgical Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA R. K. Oka, Office of Nursing Service, Veterans Affairs Central Office, Washington, DC, USA.
Clin Orthop Relat Res. 2019 Jan;477(1):177-190. doi: 10.1097/CORR.0000000000000460.
Hospital-related factors associated with mortality and morbidity after hip fracture surgery are not completely understood. The Veterans Health Administration (VHA) is the largest single-payer, networked healthcare system in the country serving a relatively homogenous patient population with facilities that vary in size and resource availability. These characteristics provide some degree of financial and patient-level controls to explore the association, if any, between surgical volume and facility resource availability and hospital performance regarding postoperative complications after hip fracture surgery.
QUESTIONS/PURPOSES: (1) Do VHA facilities with the highest complexity level designation (Level 1a) have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-complexity level facilities? (2) Do VHA facilities with higher hip fracture surgical volume have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-volume facilities?
We explored the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database from October 2001 to September 2012 for records of hip fracture surgery performed. Data reliability of the VASQIP database has been previously validated. We excluded nine of the 98 VHA facilities for contributing fewer than 30 records. The remaining 89 VHA facilities provided 23,029 records. The VHA designates a complexity level to each facility based on multiple criteria. We labeled facilities with a complexity Level 1a (38 facilities)-the highest achievable VHA designated complexity level-as high complexity; we labeled all other complexity level designations as low complexity (51 facilities). Facility volume was divided into tertiles: high (> 277 hip fracture procedures during the sampling frame), medium (204 to 277 procedures), and low (< 204 procedures). The patient population treated by low-complexity facilities was older, had a higher prevalence of severe chronic obstructive pulmonary disease (26% versus 22%, p < 0.001), and had a higher percentage of patients having surgery within 2 days of hospital admission (83% versus 76%, p < 0.001). High-complexity facilities treated more patients with recent congestive heart failure exacerbation (4% versus 3%, p < 0.001). We defined major postoperative complications as having at least one of the following: death within 30 days of surgery, cardiac arrest requiring cardiopulmonary resuscitation, new q-wave myocardial infarction, deep vein thrombosis and/or pulmonary embolism, ventilator dependence for at least 48 hours after surgery, reintubation for respiratory or cardiac failure, acute renal failure requiring renal replacement therapy, progressive renal insufficiency with a rise in serum creatinine of at least 2 mg/dL from preoperative value, pneumonia, or surgical site infection. We used the observed-to-expected ratio (O/E ratio)-a risk-adjusted metric to classify facility performance-for major postoperative complications to assess the performance of VHA facilities. Outlier facilities with 95% confidence intervals (95% CI) for O/E ratio completely less than 1.0 were labeled "exceed expectation;" those that were completely greater than 1.0 were labeled "below expectation." We compared differences in the distribution of outlier facilities between high and low-complexity facilities, and between high-, medium-, and low-volume facilities using Fisher's exact test.
We observed no association between facility complexity level and the distribution of outlier facilities (high-complexity: 5% exceeded expectation, 5% below expectation; low-complexity: 8% exceeded expectation, 2% below expectation; p = 0.742). Compared with high-complexity facilities, the adjusted odds ratio for major postoperative complications for low-complexity facilities was 0.85 (95% CI, 0.67-1.09; p = 0.108).We observed no association between facility volume and the distribution of outlier facilities: 3% exceeded expectation and 3% below expectation for high-volume; 10% exceeded expectation and 3% below expectation for medium-volume; and 7% exceeded expectation and 3% below expectation for low-volume; p = 0.890). The adjusted odds ratios for major postoperative complications were 0.87 (95% CI, 0.73-1.05) for low- versus high-volume facilities and 0.89 (95% CI, 0.79-1.02] for medium- versus high-volume facilities (p = 0.155).
These results do not support restricting facilities from treating hip fracture patients based on historical surgical volume or facility resource availability. Identification of consistent performance outliers may help health care organizations with multiple facilities determine allocation of services and identify characteristics and processes that determine outlier status in the interest of continued quality improvement.
Level III, therapeutic study.
与髋部骨折手术后死亡率和发病率相关的医院相关因素尚不完全清楚。退伍军人事务部医疗保健系统（VHA）是美国最大的单一支付者、网络化医疗体系，服务于相对同质的患者群体，其设施规模和资源可利用性各不相同。这些特征在一定程度上提供了财务和患者水平的控制，以探讨手术量和设施资源可利用性与髋部骨折手术后术后并发症之间的关联，如果有任何关联的话。
问题/目的：（1）最高复杂级别指定（Level 1a）的 VHA 设施是否与低复杂级别设施相比，在主要术后并发症方面出现异常表现的比例过高？（2）与低容量设施相比，高容量髋部骨折手术的 VHA 设施是否在主要术后并发症方面出现异常表现的比例过高？
我们从 2001 年 10 月到 2012 年 9 月期间，探索了退伍军人事务部手术质量改进项目（VASQIP）数据库，以获取髋部骨折手术记录。VASQIP 数据库的数据可靠性已经过验证。我们排除了 9 个 VHA 设施，因为它们提供的记录少于 30 份。其余 89 个 VHA 设施提供了 23029 份记录。VHA 根据多项标准对每个设施进行复杂程度指定。我们将复杂性水平为 1a（38 个设施）的设施标记为高复杂度设施；我们将所有其他复杂级别指定标记为低复杂度设施（51 个设施）。设施容量分为三分之一：高（抽样框架期间> 277 例髋部骨折手术）、中（204 至 277 例手术）和低（< 204 例手术）。低复杂度设施治疗的患者年龄较大，患有严重慢性阻塞性肺疾病的比例较高（26%对 22%，p < 0.001），并且在入院后 2 天内接受手术的患者比例较高（83%对 76%，p < 0.001）。高复杂度设施治疗的最近心力衰竭恶化患者更多（4%对 3%，p < 0.001）。我们将主要术后并发症定义为至少有一种以下情况：手术后 30 天内死亡、需要心肺复苏的心脏骤停、新 Q 波心肌梗死、深静脉血栓形成和/或肺栓塞、手术后至少 48 小时需要呼吸机支持、因呼吸或心脏衰竭重新插管、需要肾脏替代治疗的急性肾衰竭、血清肌酐从术前值上升至少 2mg/dL 的进行性肾功能不全、肺炎或手术部位感染。我们使用观察到的与预期比值（O/E 比值）-一种风险调整的指标来评估 VHA 设施的表现-来评估主要术后并发症的设施表现。O/E 比值完全小于 1.0 的 95%置信区间（95%CI）的设施被标记为“超出预期”；完全大于 1.0 的设施被标记为“低于预期”。我们使用 Fisher 精确检验比较高复杂度和低复杂度设施之间以及高容量、中容量和低容量设施之间异常设施分布的差异。
我们观察到设施复杂程度水平与异常设施分布之间没有关联（高复杂度：5%超出预期，5%低于预期；低复杂度：8%超出预期，2%低于预期；p = 0.742）。与高复杂度设施相比，低复杂度设施的主要术后并发症的调整后优势比为 0.85（95%CI，0.67-1.09；p = 0.108）。我们观察到设施容量与异常设施分布之间没有关联：高容量设施为 3%超出预期和 3%低于预期；中容量设施为 10%超出预期和 3%低于预期；低容量设施为 7%超出预期和 3%低于预期；p = 0.890）。低容量与高容量设施相比，主要术后并发症的调整后优势比为 0.87（95%CI，0.73-1.05），中容量与高容量设施相比，调整后优势比为 0.89（95%CI，0.79-1.02）（p = 0.155）。
这些结果不支持根据历史手术量或设施资源可用性限制设施治疗髋部骨折患者。确定一致的表现异常者可能有助于具有多个设施的医疗保健组织确定服务分配，并确定确定异常状态的特征和流程，以继续质量改进。
III 级，治疗研究。
