Ghith Nermin, Merlo Juan, Frølich Anne
Research Unit of Chronic Conditions, Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg University Hospital, Frederiksberg, Denmark.
Unit for Social Epidemiology, Lunds Universitet, Lund, Sweden.
BMJ Open Qual. 2019 Jan 14;8(1):e000449. doi: 10.1136/bmjoq-2018-000449. eCollection 2019.
Studies assessing institutional performance regarding quality of care are frequently performed using single-level statistical analyses investigating differences between provider averages of various quality indicators. However, such analyses are insufficient as they do not consider patients' heterogeneity around those averages. Hence, we apply a multilevel analysis of individual-patient heterogeneity that distinguishes between 'general' ('latent quality' or measures of variance) and 'specific' (measures of association) contextual effects. We assess general contextual effects of the hospital departments and the specific contextual effect of a national accreditation programme on adherence to the standard benchmark for albuminuria measurement in Danish patients with diabetes.
From the Danish Adult Diabetes Database, we extracted data on 137 893 patient cases admitted to hospitals between 2010 and 2013. Applying multilevel logistic and probit regression models for every year, we quantified general contextual effects of hospital department by the intraclass correlation coefficient (ICC) and the area under the receiver operating characteristic curve (AUC) values. We evaluated the specific effect of hospital accreditation using the ORs and the change in the department variance.
In 2010, the department context had considerable influence on adherence with albuminuria measurement (ICC=21.8%, AUC=0.770), but the general effect attenuated along with the implementation of the national accreditation programme. The ICC value was 16.5% in 2013 and the rate of compliance with albuminuria measurement increased from 91.6% in 2010 to 96% in 2013.
Parallel to implementation of the national accreditation programme, departments' compliance with the standard benchmark for albuminuria measurement increased and the ICC values decreased, but remained high. While those results indicate an overall quality improvement, further intervention focusing on departments with the lowest compliance could be considered.
评估医疗质量方面机构绩效的研究，通常采用单水平统计分析来调查不同质量指标的提供者平均值之间的差异。然而，此类分析并不充分，因为它们没有考虑这些平均值周围患者的异质性。因此，我们应用个体患者异质性的多水平分析，区分“一般”（“潜在质量”或方差度量）和“特定”（关联度量）背景效应。我们评估丹麦糖尿病患者中，医院科室的一般背景效应以及国家认证计划对蛋白尿测量标准基准依从性的特定背景效应。
从丹麦成人糖尿病数据库中，我们提取了2010年至2013年期间入院的137893例患者的数据。每年应用多水平逻辑回归和概率回归模型，我们通过组内相关系数（ICC）和受试者工作特征曲线下面积（AUC）值来量化医院科室的一般背景效应。我们使用比值比（OR）和科室方差的变化来评估医院认证的特定效应。
2010年，科室背景对蛋白尿测量的依从性有相当大的影响（ICC = 21.8%，AUC = 0.770），但随着国家认证计划的实施，一般效应减弱。2013年ICC值为16.5%，蛋白尿测量的依从率从2010年的91.6%提高到2013年的96%。
与国家认证计划的实施并行，各科室对蛋白尿测量标准基准的依从性提高，ICC值下降，但仍处于较高水平。虽然这些结果表明整体质量有所改善，但可以考虑针对依从性最低的科室进行进一步干预。
