Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, The Netherlands.
Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, the Netherlands.
Br J Surg. 2024 May 3;111(5). doi: 10.1093/bjs/znae119.
Clinical auditing is a powerful tool to evaluate and improve healthcare. Deviations from the expected quality of care are identified by benchmarking the results of individual hospitals using national averages. This study aimed to evaluate the use of quality indicators for benchmarking hepato-pancreato-biliary (HPB) surgery and when outlier hospitals could be identified.
A population-based study used data from two nationwide Dutch HPB audits (DHBA and DPCA) from 2014 to 2021. Sample size calculations determined the threshold (in percentage points) to identify centres as statistical outliers, based on current volume requirements (annual minimum of 20 resections) on a two-year period (2020-2021), covering mortality rate, failure to rescue (FTR), major morbidity rate and textbook/ideal outcome (TO) for minor liver resection (LR), major LR, pancreaticoduodenectomy (PD) and distal pancreatectomy (DP).
In total, 10 963 and 7365 patients who underwent liver and pancreatic resection respectively were included. Benchmark and corresponding range of mortality rates were 0.6% (0 -3.2%) and 3.3% (0-16.7%) for minor and major LR, and 2.7% (0-7.0%) and 0.6% (0-4.2%) for PD and DP respectively. FTR rates were 5.4% (0-33.3%), 14.2% (0-100%), 7.5% (1.6%-28.5%) and 3.1% (0-14.9%). For major morbidity rate, corresponding rates were 9.8% (0-20.5%), 28.1% (0-47.1%), 36% (15.8%-58.3%) and 22.3% (5.2%-46.1%). For TO, corresponding rates were 73.6% (61.3%-94.4%), 54.1% (35.3-100), 46.8% (25.3%-59.4%) and 63.3% (30.7%-84.6%). Mortality rate thresholds indicating a significant outlier were 8.6% and 15.4% for minor and major LR and 14.2% and 8.6% for PD and DP. For FTR, these thresholds were 17.9%, 31.6%, 22.9% and 15.0%. For major morbidity rate, these thresholds were 26.1%, 49.7%, 57.9% and 52.9% respectively. For TO, lower thresholds were 52.5%, 32.5%, 25.8% and 41.4% respectively. Higher hospital volumes decrease thresholds to detect outliers.
Current event rates and minimum volume requirements per hospital are too low to detect any meaningful between hospital differences in mortality rate and FTR. Major morbidity rate and TO are better candidates to use for benchmarking.
临床审核是评估和改善医疗保健的有力工具。通过将个别医院的结果与全国平均水平进行基准测试，可以确定护理质量的偏差。本研究旨在评估使用质量指标进行基准测试肝胰胆（HPB）手术的情况，以及何时可以确定异常值医院。
本研究采用了 2014 年至 2021 年期间两项全国性荷兰 HPB 审核（DHBA 和 DPCA）的数据进行了一项基于人群的研究。根据当前的容量要求（两年内每年至少 20 例切除术），样本量计算确定了确定中心为统计异常值的阈值（以百分比表示），包括死亡率、抢救失败（FTR）、主要发病率和肝部分切除术（LR）、主要 LR、胰十二指肠切除术（PD）和胰体尾切除术（DP）的理想/教科书结局（TO）。
共纳入 10963 例和 7365 例分别接受肝和胰腺切除术的患者。LR 小切口和大切口的基准和相应范围的死亡率分别为 0.6%（0-3.2%）和 3.3%（0-16.7%），PD 和 DP 分别为 2.7%（0-7.0%）和 0.6%（0-4.2%）。FTR 率分别为 5.4%（0-33.3%）、14.2%（0-100%）、7.5%（1.6%-28.5%）和 3.1%（0-14.9%）。主要发病率的相应比率分别为 9.8%（0-20.5%）、28.1%（0-47.1%）、36%（15.8%-58.3%）和 22.3%（5.2%-46.1%）。TO 的相应比率分别为 73.6%（61.3%-94.4%）、54.1%（35.3%-100%）、46.8%（25.3%-59.4%）和 63.3%（30.7%-84.6%）。死亡率指示显著异常的阈值分别为 8.6%和 15.4%，用于小切口和大切口 LR，以及 14.2%和 8.6%，用于 PD 和 DP。对于 FTR，这些阈值分别为 17.9%、31.6%、22.9%和 15.0%。对于主要发病率，这些阈值分别为 26.1%、49.7%、57.9%和 52.9%。对于 TO，较低的阈值分别为 52.5%、32.5%、25.8%和 41.4%。较高的医院容量降低了检测异常值的阈值。
目前的事件发生率和每个医院的最低容量要求太低，无法检测到死亡率和 FTR 方面任何有意义的医院间差异。主要发病率和 TO 是用于基准测试的更好候选者。
