Enhancing feedback on performance measures: the difference in outlier detection using a binary versus continuous outcome funnel plot and implications for quality improvement.
Enhancing feedback on performance measures: the difference in outlier detection using a binary versus continuous outcome funnel plot and implications for quality improvement.
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DOI：
10.1136/bmjqs-2019-009929
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发表时间：
2021-01
影响因子：
5.4
通讯作者：
Marang-van de Mheen PJ
中科院分区：
文献类型：
--
作者：
Kuhrij L;van Zwet E;van den Berg-Vos R;Nederkoorn P;Marang-van de Mheen PJ
医院和医疗服务提供者会收到有关其绩效与其他医院相比如何的反馈信息，通常使用漏斗图来检测异常值。这些漏斗图通常使用二元结果，并且连续变量被二分以适应这种格式。然而，使用二元测量会丢失信息，二元测量仅对检测较高值（尾部）而不是整个分布的差异敏感。因此，本研究旨在调查在使用漏斗图表示二元结果与连续结果时是否会识别出不同的异常医院。这对于绩效不佳的医院来说至关重要，以决定是否可以通过针对所有患者或具有较高价值的亚组的流程来提高绩效。我们检查了 2017 年在 65 家医院接受静脉溶栓治疗的所有（6080 名）急性缺血性卒中患者的入院至针刺时间 (DNT)，这些患者已在荷兰急性卒中审计中登记。我们在两个漏斗图中比较了离群医院：DNT 中位数与 DNT 严重延迟的患者比例（第 90 个百分位以上 (P90)），无论这些医院是同一家还是不同的医院。使用高于中位数的比例和连续 P90 漏斗图进行了两次敏感性分析。中位 DNT 为 24 分钟，P90 为 50 分钟。在 P90 以上患者比例的二元漏斗图中，58 家医院表现一般，而在中位数周围的漏斗图中，其中 14 家医院的 DNT 中位数显着较高（24%）。这些医院可能可以通过关注所有患者的护理流程来改善其 DNT，而二元结果漏斗图并未显示这一点。敏感性分析也显示了类似的结果。使用连续与二元结果的漏斗图可以识别不同的异常医院，这可以增强医院的反馈，以指导更有针对性的改进举措。
Hospitals and providers receive feedback information on how their performance compares with others, often using funnel plots to detect outliers. These funnel plots typically use binary outcomes, and continuous variables are dichotomised to fit this format. However, information is lost using a binary measure, which is only sensitive to detect differences in higher values (the tail) rather than the entire distribution. This study therefore aims to investigate whether different outlier hospitals are identified when using a funnel plot for a binary vs a continuous outcome. This is relevant for hospitals with suboptimal performance to decide whether performance can be improved by targeting processes for all patients or a subgroup with higher values. We examined the door-to-needle time (DNT) of all (6080) patients with acute ischaemic stroke treated with intravenous thrombolysis in 65 hospitals in 2017, registered in the Dutch Acute Stroke Audit. We compared outlier hospitals in two funnel plots: the median DNT versus the proportion of patients with substantially delayed DNT (above the 90th percentile (P90)), whether these were the same or different hospitals. Two sensitivity analyses were performed using the proportion above the median and a continuous P90 funnel plot. The median DNT was 24 min and P90 was 50 min. In the binary funnel plot for the proportion of patients above P90, 58 hospitals had average performance, whereas in the funnel plot around the median 14 of these hospitals had significantly higher median DNT (24%). These hospitals can likely improve their DNT by focusing on care processes for all patients, not shown by the binary outcome funnel plot. Similar results were shown in sensitivity analyses. Using funnel plots for continuous versus binary outcomes identify different outlier hospitals, which may enhance hospital feedback to direct more targeted improvement initiatives.
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