Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
J Urol. 2019 Sep;202(3):490-497. doi: 10.1097/JU.0000000000000282. Epub 2019 Aug 8.
Measuring quality is a high priority for health care systems globally. Despite the high perioperative morbidity, mortality, expenditures and performance variation of radical cystectomy there is a paucity of validated bladder cancer quality metrics. We aimed to create a hospital quality scoring system for radical cystectomy which is disease specific and associated with patient centered outcomes.
We used the National Cancer Database to identify hospitals where radical cystectomy was performed from 2004 to 2014. Mixed effects models were constructed to assess variation in hospital performance across 7 quality indicators. Indirect standardization was used to case mix adjust hospital performance. We assessed associations between quality indicators as well as the novel BC-QS (Bladder Cancer Quality Score) composite hospital quality metric with 30-day, 90-day and overall mortality using logistic and Cox regression, respectively.
At 1,200 facilities radical cystectomy was performed in a total of 48,341 patients from 2004 to 2014. Mixed effects models demonstrated significant between hospital variation across all quality indicators after case mix adjustment. The composite BC-QS metric was composed of the hospital positive margin rate, the lymph node dissection rate and the neoadjuvant chemotherapy rate. Better BC-QS performance was associated with lower 30-day and 90-day mortality (adjusted OR 0.78, 95% CI 0.64-0.96, and OR 0.84, 95% CI 0.72-0.97, respectively) and overall mortality (HR 0.86, 95% CI 0.81-0.92). Hospitals with a higher BC-QS had higher volume and more were affiliated with an academic institution than hospitals with a lower BC-QS (p <0.0001).
The BC-QS captures variations in the hospital performance of radical cystectomy and it shows an association of higher quality with lower patient mortality. Our validation of this quality metric provides support for its potential use by policy makers and payers in efforts to measure hospital quality for high cost surgeries.
衡量医疗质量是全球各国医疗体系的重中之重。尽管根治性膀胱切除术围手术期发病率、死亡率、支出和绩效差异较大，但目前缺乏经过验证的膀胱癌质量指标。我们旨在建立一个专门针对膀胱癌的根治性膀胱切除术医院质量评分系统，该系统与以患者为中心的结果相关。
我们使用国家癌症数据库，从 2004 年至 2014 年，确定进行根治性膀胱切除术的医院。采用混合效应模型评估 7 项质量指标在医院绩效方面的差异。间接标准化用于调整医院绩效的病例组合。我们使用逻辑回归和 Cox 回归，分别评估质量指标之间以及新型膀胱癌质量评分（BC-QS）综合医院质量指标与 30 天、90 天和总死亡率之间的关联。
在 2004 年至 2014 年间，共有 1200 家医疗机构对 48341 名患者进行了根治性膀胱切除术。混合效应模型显示，经过病例组合调整后，所有质量指标的医院间差异具有统计学意义。综合 BC-QS 指标由医院阳性切缘率、淋巴结清扫率和新辅助化疗率组成。更好的 BC-QS 表现与较低的 30 天和 90 天死亡率（调整后的 OR 0.78，95%CI 0.64-0.96 和 OR 0.84，95%CI 0.72-0.97）和总死亡率（HR 0.86，95%CI 0.81-0.92）相关。BC-QS 较高的医院手术量较高，并且与 BC-QS 较低的医院相比，更多的医院与学术机构有关联（p<0.0001）。
BC-QS 能够捕捉根治性膀胱切除术医院绩效的变化，并且表明更高的质量与更低的患者死亡率相关。我们对该质量指标的验证为决策者和支付方在努力衡量高成本手术的医院质量时使用该指标提供了支持。
