Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
Department of Surgery, University of Verona, Verona, Italy.
Ann Surg. 2020 Jun;271(6):1116-1123. doi: 10.1097/SLA.0000000000003105.
To define and test "Textbook Outcome" (TO)-a composite measure for healthcare quality-among Medicare patients undergoing hepatopancreatic resections. Hospital variation in TO and Medicare payments were analyzed.
Composite measures of quality may be superior to individual measures for the analysis of hospital performance.
The Medicare Provider Analysis and Review (MEDPAR) Inpatient Files were reviewed to identify Medicare patients who underwent pancreatic and liver procedures between 2013 and 2015. TO was defined as: no postoperative surgical complications, no prolonged length of hospital stay, no readmission ≤ 90 days after discharge, and no postoperative mortality ≤ 90 days after surgery. Medicare payments were compared among patients who achieved TO versus patients who did not. Multivariable logistic regression was used to investigate patient factors associated with TO. A nomogram to predict probability of TO was developed and validated.
TO was achieved in 44% (n = 5919) of 13,467 patients undergoing hepatopancreatic surgery. Adjusted TO rates at the hospital level varied from 11.1% to 69.6% for pancreatic procedures and from 16.6% to 78.7% for liver procedures. Prolonged length of hospital stay represented the major obstacle to achieve TO. Average Medicare payments were substantially higher among patients who did not have a TO. Factors associated with TO on multivariable analysis were age, sex, Charlson comorbidity score, previous hospital admissions, procedure type, and surgical approach (all P > 0.05).
Less than one-half of Medicare patients achieved a TO following hepatopancreatic procedures with a wide variation in the rates of TO among hospitals. There was a discrepancy in Medicare payments for patients who achieved a TO versus patients who did not. TO could be useful for the public reporting of patient level hospital performance and hospital variation.
定义并检验“教科书结局”（Textbook Outcome，TO）——一种用于衡量接受肝胰切除术的 Medicare 患者医疗质量的综合指标。分析了医院之间 TO 及 Medicare 支付的差异。
质量的综合指标可能优于单个指标，用于分析医院绩效。
对 Medicare 提供者分析和审查（Medicare Provider Analysis and Review，MEDPAR）住院患者记录进行了回顾，以确定 2013 年至 2015 年间接受胰腺和肝脏手术的 Medicare 患者。TO 定义为：无术后手术并发症、无延长住院时间、无 90 天内再入院和无术后 90 天内死亡。比较了达到 TO 与未达到 TO 的患者的 Medicare 支付。采用多变量逻辑回归分析与 TO 相关的患者因素。制定并验证了预测 TO 概率的列线图。
在 13467 例接受肝胰切除术的患者中，有 44%（n=5919）达到了 TO。医院层面的调整后 TO 率，胰腺手术为 11.1%至 69.6%，肝脏手术为 16.6%至 78.7%。延长住院时间是达到 TO 的主要障碍。未达到 TO 的患者的 Medicare 支付平均要高得多。多变量分析中与 TO 相关的因素有年龄、性别、Charlson 合并症评分、既往住院史、手术类型和手术方式（均 P＞0.05）。
在接受肝胰切除术的 Medicare 患者中，不到一半的患者达到了 TO，而医院间 TO 的发生率差异很大。达到 TO 的患者与未达到 TO 的患者之间的 Medicare 支付存在差异。TO 可用于报告患者层面的医院绩效和医院间的差异。
