Hannan E L, Racz M J, Jollis J G, Peterson E D
Department of Health Policy and Management, School of Public Health, State University of New York at Albany 1244-3456, USA.
Health Serv Res. 1997 Feb;31(6):659-78.
To assess the relative abilities of clinical and administrative data to predict mortality and to assess hospital quality of care for CABG surgery patients.
DATA SOURCES/STUDY SETTING: 1991-1992 data from New York's Cardiac Surgery Reporting System (clinical data) and HCFA's MEDPAR (administrative data). STUDY DESIGN/SETTING/SAMPLE: This is an observational study that identifies significant risk factors for in-hospital mortality and that risk-adjusts hospital mortality rates using these variables. Setting was all 31 hospitals in New York State in which CABG surgery was performed in 1991-1992. A total of 13,577 patients undergoing isolated CABG surgery who could be matched in the two databases made up the sample.
Hospital risk-adjusted mortality rates, identification of "outlier" hospitals, and discrimination and calibration of statistical models were the main outcome measures.
Part of the discriminatory power of administrative statistical models resulted from the miscoding of postoperative complications as comorbidities. Removal of these complications led to deterioration in the model's C index (from C = .78 to C = .71 and C = .73). Also, provider performance assessments changed considerably when complications of care were distinguished from comorbidities. The addition of a couple of clinical data elements considerably improved the fit of administrative models. Further, a clinical model based on Medicare CABG patients yielded only three outliers, whereas eight were identified using a clinical model for all CABG patients.
If administrative databases are used in outcomes research, (1) efforts to distinguish complications of care from comorbidities should be undertaken, (2) much more accurate assessments may be obtained by appending a limited number of clinical data elements to administrative data before assessing outcomes, and (3) Medicare data may be misleading because they do not reflect outcomes for all patients.
评估临床数据和管理数据预测死亡率的相对能力，并评估冠状动脉搭桥术（CABG）患者的医院护理质量。
数据来源/研究背景：来自纽约心脏手术报告系统的1991 - 1992年数据（临床数据）和医疗保健财务管理局（HCFA）的医疗费用报销数据（管理数据）。研究设计/背景/样本：这是一项观察性研究，旨在确定住院死亡率的显著风险因素，并使用这些变量对医院死亡率进行风险调整。研究背景为1991 - 1992年在纽约州进行CABG手术的所有31家医院。两个数据库中总共13577例接受单纯CABG手术且可匹配的患者构成了样本。
医院风险调整死亡率、“异常”医院的识别以及统计模型的区分度和校准是主要结局指标。
管理统计模型的部分区分能力源于将术后并发症误编码为合并症。去除这些并发症导致模型的C指数下降（从C = 0.78降至C = 0.71和C = 0.73）。此外，当将护理并发症与合并症区分开来时，医疗服务提供者的绩效评估发生了很大变化。添加一些临床数据元素显著改善了管理模型的拟合度。此外，基于医疗保险CABG患者的临床模型仅识别出3家异常医院，而使用所有CABG患者的临床模型则识别出8家。
如果在结局研究中使用管理数据库，（1）应努力区分护理并发症和合并症；（2）在评估结局之前，通过在管理数据中附加有限数量的临床数据元素，可能会获得更准确的评估；（3）医疗保险数据可能会产生误导，因为它们不能反映所有患者的结局。
