失败救援对儿科创伤医院质量的评估价值。
The value of failure to rescue in determining hospital quality for pediatric trauma.
机构信息
From the Department of Pediatric Surgery (E.H.R., B.J., S.R.S., A.M.V., B.N-M.), and Outcomes & Impact Services (W.Z.), Texas Children's Hospital and Baylor College of Medicine, Houston, Texas.
出版信息
J Trauma Acute Care Surg. 2019 Oct;87(4):794-799. doi: 10.1097/TA.0000000000002240.
BACKGROUND
In adult trauma patients, high- and low-mortality trauma hospitals have similar rates of major complications but differ based on failure to rescue (mortality following a major complication), which has become a marker of hospital quality. The aim of this study is to examine whether failure to rescue is also an appropriate hospital quality indicator in pediatric trauma.
METHODS
Children younger than 15 years were identified in the 2007 to 2014 National Trauma Databank research data sets. Hospitals were classified as a high, average or low mortality based on risk-adjusted observed-to-expected in-hospital mortality ratios using the modified Trauma Mortality Probability Model. Regression modeling was used to explore the impact of hospital quality ranking on the incidence of major complications and failure to rescue.
RESULTS
Of 125,057 children, 31,600 were treated at low-mortality outlier hospitals, and 7,014 at high-mortality outlier hospitals. Low-mortality hospitals had a lower rate of major complications compared with high-mortality hospitals (0.5% [low] vs. 0.8% [high]; adjusted odds ratio [OR], 0.71; 95% confidence interval [CI], 0.61-0.83; p < 0.01) and a lower failure-to-rescue rate (17.6% [low] vs. 24.1% [high]; adjusted OR, 0.53 [high; 95% CI 0.34-0.83; p < 0.01]). When patients who died within 48 hours were excluded, low-mortality hospitals had a lower complication rate (OR, 0.81; 95% CI, 0.68, 0.96; p = 0.02), but similar failure-to-rescue rate compared to high-mortality hospitals. There was no correlation between trauma verification level and hospital mortality status based on the model.
CONCLUSION
For pediatric trauma patients, mortality is more strongly associated with major complication rate than with failure to rescue. Thus, failure to rescue does not appear to be the key driver of hospital quality in this population as it does in the adult trauma population.
LEVEL OF EVIDENCE
Prognostic and epidemiological, level III.
背景
在成人创伤患者中，高死亡率和低死亡率创伤医院的主要并发症发生率相似，但在未能抢救（主要并发症后的死亡率）方面存在差异，这已成为医院质量的标志。本研究旨在探讨未能抢救是否也是儿科创伤的合适医院质量指标。
方法
在 2007 年至 2014 年国家创伤数据库研究数据集中，确定年龄小于 15 岁的儿童。根据使用改良创伤死亡率概率模型计算的风险调整观察到的预期院内死亡率比值，将医院分为高、中、低死亡率。回归模型用于探讨医院质量排名对主要并发症和未能抢救的发生率的影响。
结果
在 125057 名儿童中，31600 名在低死亡率离群值医院接受治疗，7014 名在高死亡率离群值医院接受治疗。与高死亡率医院相比，低死亡率医院的主要并发症发生率较低（0.5%[低]比 0.8%[高]；调整后的优势比[OR]，0.71；95%置信区间[CI]，0.61-0.83；p<0.01），未能抢救的发生率也较低（17.6%[低]比 24.1%[高]；调整后的 OR，0.53[高]；95%CI 0.34-0.83；p<0.01）。当排除 48 小时内死亡的患者后，低死亡率医院的并发症发生率较低（OR，0.81；95%CI，0.68，0.96；p=0.02），但与高死亡率医院的未能抢救率相似。根据该模型，创伤验证水平与医院死亡率状态之间没有相关性。
结论
对于儿科创伤患者，死亡率与主要并发症发生率的相关性强于与未能抢救的相关性。因此，在该人群中，未能抢救似乎不是医院质量的关键驱动因素，而在成人创伤人群中则是。
证据水平
预后和流行病学，III 级。
Zotero 插件