Rockall T A, Logan R F, Devlin H B, Northfield T C
Royal College of Surgeons Epidemiology and Audit Unit, London, UK.
Lancet. 1995 Aug 5;346(8971):346-50. doi: 10.1016/s0140-6736(95)92227-x.
Hospital mortality after acute upper gastrointestinal haemorrhage varies widely. In a population-based, multi-centre, prospective survey of the management and outcome of unselected cases of acute upper gastrointestinal haemorrhage, we have assessed the effect of risk standardisation on this variation. We collected data from 74 acute hospitals in four health regions in the UK on patients aged 16 years and over who presented with acute upper gastrointestinal haemorrhage during 4 months in 1993 (3981 cases) and 3 months in 1994 (1584 cases). The overall mortality was 14.3% (798/5565). Crude mortality in individual hospitals ranged from 0% to 29%, and differed significantly from the overall rate in eight. Risk-standardised mortality ratios were calculated with a risk score derived from well-established risk factors. Only two hospitals had standardised mortality ratios significantly different from the reference value. When hospitals were ranked in order of increasing mortality, risk standardisation for age, shock, and comorbidity resulted in 21 of the 74 hospitals changing ranks by ten or more places. After further standardisation for diagnosis, endoscopic stigmata of recent haemorrhage, and rebleeding, 32 hospitals moved ten or more places from their original rank; one hospital moved 45 places. Risk standardisation to correct for variation in case mix results in apparently significant differences in mortality rates becoming non-significant. The current state of routine data collection does not allow for anything but the most basic case-mix adjustment to be made. Simple league tables of crude mortality are misleading in this disorder and cannot be regarded as a reflection of the quality of health care.
急性上消化道出血后的医院死亡率差异很大。在一项基于人群的多中心前瞻性调查中，我们对未选择的急性上消化道出血病例的管理和结局进行了评估，以研究风险标准化对这种差异的影响。我们收集了英国四个卫生区域的74家急症医院的数据，这些数据来自1993年4个月（3981例）和1994年3个月（1584例）期间出现急性上消化道出血的16岁及以上患者。总体死亡率为14.3%（798/5565）。各医院的粗死亡率在0%至29%之间，其中八家医院的粗死亡率与总体死亡率有显著差异。使用从公认的风险因素得出的风险评分计算风险标准化死亡率比值。只有两家医院的标准化死亡率比值与参考值有显著差异。当按照死亡率升序对医院进行排名时，对年龄、休克和合并症进行风险标准化后，74家医院中有21家的排名变动了十个或更多名次。在对诊断、近期出血的内镜下表现和再出血进行进一步标准化后，32家医院的排名比原来变动了十个或更多名次；一家医院变动了45个名次。通过风险标准化来纠正病例组合的差异，会使明显显著的死亡率差异变得不显著。目前常规数据收集的状况除了进行最基本的病例组合调整外，无法做更多事情。在这种疾病中，简单的粗死亡率排行榜会产生误导，不能被视为医疗质量的反映。
