When Policy Gets It Right: Variability in U.S. Hospitals' Diagnosis of Ventilator-Associated Pneumonia
When Policy Gets It Right: Variability in U.S. Hospitals' Diagnosis of Ventilator-Associated Pneumonia
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DOI：
10.1097/ccm.0b013e3182a66903
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发表时间：
2014-03-01
影响因子：
8.8
通讯作者：
Howell, Michael D.
中科院分区：
文献类型：
--
作者：
Stevens, Jennifer P.;Kachniarz, Bartlomiej;Howell, Michael D.
目的：美国疾病控制中心最近提出了一个呼吸机相关性肺炎定义的重大变化。这对ICU的公共报告、报销和问责措施具有深远的影响。我们试图提供证据支持或反对这一变化，通过量化的局限性的国家定义的呼吸机相关性肺炎是到位，直到2013年1月，特别是关于比较，排名，医院和ICUs.Design：前瞻性调查的一个全国代表性的43家医院，随机选择从美国医院协会指南（2009年）。Subjects classified six standardized vignettes of possible cases of ventilator-associated pneumonia as pneumonia or no pneumonia.Subjects：Individuals responsible for ventilator-associated pneumonia monitoring at 43 U.S. hospitals.Interventions：None.Measurements and Main Results：我们测量了标准化病例分类为呼吸机相关肺炎的比例。在138家同意的医院中，61家部分完成调查，43家完全完成调查（应答率分别为44%和31%）。医院之间关于呼吸机相关性肺炎/非呼吸机相关性肺炎病例分类的一致性几乎是随机的（Fleiss 0.13）。一些医院将0%的病例归类为肺炎;其他医院将100%的病例归类为肺炎（中位数，50%;四分位数范围，33-66%）。虽然国家的地区不能预测病例分配，但将其地区描述为农村的受访者比其他地区的受访者更有可能将病例判断为肺炎（相对危险度，1.25，Kruskal-Wallis卡方检验，p = 0.03）。在这项具有全国代表性的医院研究中，呼吸机相关性肺炎的分配差异极大，这足以使医院之间的比较变得毫无价值，即使标准化的病例消除了临床数据提取中的可变性。这种变异性的程度突出了使用表现不佳的监测定义作为医院评估和比较方法的局限性，我们的研究为转向更客观的呼吸机相关并发症定义提供了非常有力的支持。
Objective: The Centers for Disease Control has recently proposed a major change in how ventilator-associated pneumonia is defined. This has profound implications for public reporting, reimbursement, and accountability measures for ICUs. We sought to provide evidence for or against this change by quantifying limitations of the national definition of ventilator-associated pneumonia that was in place until January 2013, particularly with regard to comparisons between, and ranking of, hospitals and ICUs.Design: A prospective survey of a nationally representative group of 43 hospitals, randomly selected from the American Hospital Association Guide (2009). Subjects classified six standardized vignettes of possible cases of ventilator-associated pneumonia as pneumonia or no pneumonia.Subjects: Individuals responsible for ventilator-associated pneumonia surveillance at 43 U.S. hospitals.Interventions: None.Measurements and Main Results: We measured the proportion of standardized cases classified as ventilator-associated pneumonia. Of 138 hospitals consented, 61 partially completed the survey and 43 fully completed the survey (response rate 44% and 31%, respectively). Agreement among hospitals about classification of cases as ventilator-associated pneumonia/not ventilator-associated pneumonia was nearly random (Fleiss 0.13). Some hospitals rated 0% of cases as having pneumonia; others classified 100% as having pneumonia (median, 50%; interquartile range, 33-66%). Although region of the country did not predict case assignment, respondents who described their region as rural were more likely to judge a case to be pneumonia than respondents elsewhere (relative risk, 1.25, Kruskal-Wallis chi-square, p = 0.03).Conclusions: In this nationally representative study of hospitals, assignment of ventilator-associated pneumonia is extremely variable, enough to render comparisons between hospitals worthless, even when standardized cases eliminate variability in clinical data abstraction. The magnitude of this variability highlights the limitations of using poorly performing surveillance definitions as methods of hospital evaluation and comparison, and our study provides very strong support for moving to a more objective definition of ventilator-associated complications.