Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
Department of Public Health, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
Value Health. 2020 Sep;23(9):1191-1199. doi: 10.1016/j.jval.2019.12.014. Epub 2020 Aug 18.
Hospital comparisons to improve quality of care require valid and reliable quality indicators. We aimed to test the validity and reliability of 6 breast cancer indicators by quantifying the influence of case-mix and random variation.
The nationwide population-based database included 79 690 patients with breast cancer from 91 Dutch hospitals between 2011 and 2016. The indicator-scores calculated were: (1) irradical breast-conserving surgery (BCS) for invasive disease, (2) irradical BCS for ductal carcinoma-in-situ, (3) breast contour-preserving treatment, (4) magnetic resonance imaging (MRI) before neo-adjuvant chemotherapy, (5) radiotherapy for locally advanced disease, and (6) surgery within 5 weeks from diagnosis. Case-mix and random variation adjustments were performed by multivariable fixed and random effect logistic regression models. Rankability quantified the between-hospital variation, representing unexplained differences that might be the result of the level of quality of care, as low (<50%), moderate (50%-75%), or high (>75%).
All of the indicators showed between-hospital variation with wide (interquartile) ranges. Case-mix adjustment reduced variation in indicators 1 and 3 to 5. Random variation adjustment (further) reduced the variation for all indicators. Case-mix and random variation adjustments influenced the indicator-scores of individual hospitals and their ranking. Rankability was poor for indicator 1, 2, and 5, and moderate for 3, 4, and 6.
The 6 indicators lacked validity and/or reliability to a certain extent. Although measuring quality indicators may stimulate quality improvement in general, comparisons and judgments of individual hospital performance should be made with caution if based on indicators that have not been tested or adjusted for validity and reliability, especially in benchmarking.
为了提高医疗质量，需要对医院进行比较，这就需要使用有效且可靠的质量指标。本研究旨在通过量化病例组合和随机变异的影响，来检验 6 项乳腺癌指标的有效性和可靠性。
本研究基于全国性的人群数据库，纳入了 2011 年至 2016 年期间 91 家荷兰医院的 79690 例乳腺癌患者。计算的指标评分包括：（1）浸润性乳腺癌保乳手术（BCS）评分，（2）导管原位癌保乳手术评分，（3）乳房轮廓保存治疗评分，（4）新辅助化疗前磁共振成像（MRI）评分，（5）局部晚期疾病放疗评分，以及（6）诊断后 5 周内手术评分。采用多变量固定和随机效应逻辑回归模型进行病例组合和随机变异调整。分级能力量化了医院间的差异，代表了可能是护理质量水平的结果的未解释差异，低（<50%）、中（50%-75%）或高（>75%）。
所有指标均显示出医院间差异较大（四分位距）。病例组合调整将指标 1 和 3 的差异缩小到 5%。随机变异调整（进一步）降低了所有指标的差异。病例组合和随机变异调整影响了个别医院的指标评分及其排名。指标 1、2 和 5 的分级能力较差，指标 3、4 和 6 的分级能力中等。
这 6 项指标在一定程度上缺乏有效性和/或可靠性。尽管测量质量指标可能会普遍刺激质量改进，但如果基于未经有效性和可靠性检验或调整的指标进行个别医院绩效的比较和判断，尤其是在基准测试中，应谨慎行事。
