From the Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery (M.P.D., A.A.M., K.M.S., K.A.D., R.D.B.), Yale School of Medicine, New Haven, Connecticut; Yale Center for Analytical Sciences, Yale School of Public Health (N.S., M.J.S.), New Haven, Connecticut; and Section of Geriatrics, Department of Internal Medicine (T.M.G.), Yale School of Medicine, New Haven, Connecticut.
J Trauma Acute Care Surg. 2019 Aug;87(2):289-296. doi: 10.1097/TA.0000000000002367.
There is a longstanding interest in the field of management science to study high performance organizations. Applied to medicine, research on hospital performance indicates that some hospitals are high performing, while others are not. The objective of this study was to identify a cluster of high-performing emergency general surgery (EGS) hospitals and assess whether high performance at one EGS operation was associated with high performance on all EGS operations.
Adult patients who underwent one of eight EGS operations were identified in the California State Inpatient Database (2010-2011), which we linked to the American Hospital Association database. Beta regression was used to estimate a hospital's risk-adjusted mortality, accounting for patient- and hospital-level factors. Centroid cluster analysis grouped hospitals by patterns of mortality rates across the eight EGS operations using z scores. Multinomial logistic regression compared hospital characteristics by cluster.
A total of 220 acute care hospitals were included. Three distinct clusters of hospitals were defined based on assessment of mortality for each operation type: high-performing hospitals (n = 66), average performing (n = 99), and low performing (n = 55). The mortality by individual operation type at the high-performing cluster was consistently at least 1.5 standard deviations better than the low-performing cluster (p < 0.001). Within-cluster variation was minimal at high-performing hospitals compared with wide variation at low-performing hospitals. A hospital's high performance in one EGS operation type predicted high performance on all EGS operation types.
High-performing EGS hospitals attain excellence across all types of EGS operations, with minimal variability in mortality. Poor-performing hospitals are persistently below average, even for low-risk operations. These findings suggest that top-performing EGS hospitals are highly reliable, with systems of care in place to achieve consistently superior results. Further investigation and collaboration are needed to identify the factors associated with high performance.
Prognostic, level III.
管理科学领域长期以来一直对研究高绩效组织感兴趣。将其应用于医学领域，对医院绩效的研究表明，一些医院绩效较高，而另一些医院则不然。本研究的目的是确定一组高绩效的急诊普通外科（EGS）医院，并评估在一项 EGS 手术中表现出色是否与在所有 EGS 手术中表现出色相关。
在加利福尼亚州住院患者数据库（2010-2011 年）中确定接受八项 EGS 手术之一的成年患者，并将其与美国医院协会数据库相关联。使用贝塔回归来估计医院的风险调整死亡率，同时考虑患者和医院层面的因素。质心聚类分析使用 z 分数根据八项 EGS 手术的死亡率模式对医院进行分组。多分类逻辑回归比较了按聚类分组的医院特征。
共纳入 220 家急症护理医院。根据每种手术类型的死亡率评估，定义了三个不同的医院集群：高绩效医院（n = 66）、平均绩效医院（n = 99）和低绩效医院（n = 55）。高绩效集群中每种手术类型的死亡率始终比低绩效集群至少好 1.5 个标准差（p < 0.001）。与低绩效医院相比，高绩效医院的内部聚类变异性极小。医院在一种 EGS 手术类型中的表现出色可预测在所有 EGS 手术类型中的表现出色。
高绩效的 EGS 医院在所有类型的 EGS 手术中都表现出色，死亡率的变异性极小。绩效不佳的医院始终低于平均水平，即使是低风险的手术也是如此。这些发现表明，顶尖的 EGS 医院具有高度可靠性，其护理系统能够始终如一地取得卓越的成果。需要进一步调查和合作，以确定与高绩效相关的因素。
预后，III 级。
