美国心脏手术医院 90 天风险标准化出院时间绩效指标
Ninety-Day Risk-Standardized Home Time as a Performance Metric for Cardiac Surgery Hospitals in the United States.
机构信息
Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, OH (A.M., M.Y.D., A.M.G., D.J., S.K., L.S.).
Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.K., D.J.K., E.D.P., A.P.).
出版信息
Circulation. 2022 Oct 25;146(17):1297-1309. doi: 10.1161/CIRCULATIONAHA.122.059496. Epub 2022 Sep 26.
BACKGROUND
Assessing hospital performance for cardiac surgery necessitates consistent and valid care quality metrics. The association of hospital-level risk-standardized home time for cardiac surgeries with other performance metrics such as mortality rate, readmission rate, and annual surgical volume has not been evaluated previously.
METHODS
The study included Medicare beneficiaries who underwent isolated or concomitant coronary artery bypass graft, aortic valve, or mitral valve surgery from January 1, 2013, to October 1, 2019. Hospital-level performance metrics of annual surgical volume, 90-day risk-standardized mortality rate, 90-day risk-standardized readmission rate, and 90-day risk-standardized home time were estimated starting from the day of surgery using generalized linear mixed models with a random intercept for the hospital. Correlations between the performance metrics were assessed using the Pearson correlation coefficient. Patient-level clinical outcomes were also compared across hospital quartiles by 90-day risk-standardized home time. Last, the temporal stability of performance metrics for each hospital during the study years was also assessed.
RESULTS
Overall, 919 698 patients (age 74.2±5.8 years, 32% women) were included from 1179 hospitals. Median 90-day risk-standardized home time was 71.2 days (25th-75th percentile, 66.5-75.6), 90-day risk-standardized readmission rate was 26.0% (19.5%-35.7%), and 90-day risk-standardized mortality rate was 6.0% (4.0%-8.8%). Across 90-day home time quartiles, a graded decline was observed in the rates of in-hospital, 90-day, and 1-year mortality, and 90-day and 1-year readmission. Ninety-day home time had a significant positive correlation with annual surgical volume (=0.31; <0.001) and inverse correlation with 90-day risk-standardized readmission rate (=-0.40; <0.001) and 90-day risk-standardized mortality rate (=-0.60; <0.001). Use of 90-day home time as a performance metric resulted in a meaningful reclassification in performance ranking of 22.8% hospitals compared with annual surgical volume, 11.6% compared with 90-day risk-standardized mortality rate, and 19.9% compared with 90-day risk-standardized readmission rate. Across the 7 years of the study period, 90-day home time demonstrated the most temporal stability of the hospital performance metrics.
CONCLUSIONS
Ninety-day risk-standardized home time is a feasible, comprehensive, patient-centered metric to assess hospital-level performance in cardiac surgery with greater temporal stability than mortality and readmission measures.
背景
评估心脏手术的医院绩效需要一致且有效的护理质量指标。此前尚未评估医院层面风险标准化出院时间与其他绩效指标（如死亡率、再入院率和年度手术量）之间的相关性。
方法
该研究纳入了 2013 年 1 月 1 日至 2019 年 10 月 1 日期间接受单纯或联合冠状动脉旁路移植术、主动脉瓣或二尖瓣手术的 Medicare 受益人的数据。使用具有医院随机截距的广义线性混合模型，从手术日起估算医院层面的年度手术量、90 天风险标准化死亡率、90 天风险标准化再入院率和 90 天风险标准化出院时间等绩效指标。使用 Pearson 相关系数评估绩效指标之间的相关性。还根据 90 天风险标准化出院时间，比较了患者水平临床结局在医院四分位数之间的差异。最后，还评估了每个医院在研究期间绩效指标的时间稳定性。
结果
共有来自 1179 家医院的 919698 名患者（年龄 74.2±5.8 岁，32%为女性）纳入研究。中位 90 天风险标准化出院时间为 71.2 天（25 百分位至 75 百分位为 66.5-75.6），90 天风险标准化再入院率为 26.0%（19.5%-35.7%），90 天风险标准化死亡率为 6.0%（4.0%-8.8%）。在 90 天出院时间四分位数中，住院、90 天和 1 年死亡率以及 90 天和 1 年再入院率均呈逐渐下降趋势。90 天出院时间与年度手术量呈显著正相关（=0.31；<0.001），与 90 天风险标准化再入院率呈负相关（=-0.40；<0.001），与 90 天风险标准化死亡率呈负相关（=-0.60；<0.001）。与年度手术量相比，使用 90 天风险标准化出院时间作为绩效指标可使 22.8%的医院在绩效排名上发生显著变化，与 90 天风险标准化死亡率相比可使 11.6%的医院发生变化，与 90 天风险标准化再入院率相比可使 19.9%的医院发生变化。在研究的 7 年期间，90 天风险标准化出院时间表现出了医院绩效指标中最强的时间稳定性。
结论
90 天风险标准化出院时间是一种可行的、全面的、以患者为中心的心脏手术医院绩效评估指标，其时间稳定性优于死亡率和再入院率指标。
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