CONTINUOUS ASSESSMENT AND IMPROVEMENT IN QUALITY OF CARE - A MODEL FROM THE DEPARTMENT-OF-VETERANS-AFFAIRS CARDIAC-SURGERY
CONTINUOUS ASSESSMENT AND IMPROVEMENT IN QUALITY OF CARE - A MODEL FROM THE DEPARTMENT-OF-VETERANS-AFFAIRS CARDIAC-SURGERY
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DOI：
10.1097/00000658-199403000-00008
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发表时间：
1994-03-01
影响因子：
9
通讯作者：
GROVER, FL
中科院分区：
文献类型：
--
作者：
HAMMERMEISTER, KE;JOHNSON, R;GROVER, FL
目的作者组织了退伍军人事务部(VA)心脏外科持续改进研究(CICSS)，以提供风险调整后的结果数据，为在退伍军人事务部接受心脏手术的所有患者提供持续评估和改善护理质量的数据。背景使用风险调整后的结果来监测卫生保健质量比共识标准具有潜在的优势，即在如何提供卫生保健方面没有先入为主的偏见。监测所有保健事件的结果，而不是审查选定的病例(例如，不良结果)，具有更大的统计权力，有机会比较护理过程的好与坏结果，以及平等对待所有提供者的积极心理。这两个概念与一个预先存在的同行委员会(退伍军人管理局心脏手术顾问委员会)一起审查、解释风险调整后的结果数据并对其采取行动，构成了CICSS的主要设计考虑因素。方法前瞻性地收集每年在退伍军人事务部接受心脏手术的大约7000名患者的患者水平的风险和结果(手术死亡率和发病率)数据。这些结果通过Logistic回归根据患者风险进行调整，每6个月提供给每个心脏手术计划和国家同行审查委员会进行内部和外部质量评估和改进。结果在最近12个月的完整数据收集期间，观察与预期(O/E)比率从0.2到2.2，其中8个中心低于O/E比率等于1.0的90%置信限。在该项目的4.5年期间，所有中心的O/E比下降了14%(p=0.06)。结论利用风险调整的结果进行大规模、低成本的持续质量改进项目是可行的。这项计划与风险调整后手术死亡率的降低有关。
Objective The authors organized the Department of Veterans Affairs (VA) Continuous Improvement in Cardiac Surgery Study (CICSS) to provide risk-adjusted outcome data for the continuous assessment and improvement of quality of care for all patients undergoing cardiac surgery in the VA.Background The use of risk-adjusted outcomes to monitor quality of health care has the potential advantage over consensus-derived standards of being free of preconceived biases about how health care should be provided. Monitoring outcomes of all health care episodes, as opposed to review of selected cases (e.g., adverse outcomes), has the advantages of greater statistical power, the opportunity to compare processes of care between good and bad outcomes, and the positive psychology of treating all providers equally. These two concepts, together with a pre-existing peer committee (the VA Cardiac Surgery Consultants Committee) to review, interpret, and act on the risk-adjusted outcome data, form the primary design considerations for CICSS.Methods Patient-level risk and outcome (operative mortality and morbidity) data are collected prospectively on each of the approximately 7000 patients undergoing cardiac surgery in the VA each year. These outcomes, adjusted for patient risk using logistic regression, are provided every 6 months to each cardiac surgery program and to a national peer review committee for internal and external quality assessment and improvement.Results For the most recent 12-month period with complete data collection, observed-to-expected (O/E) ratios ranged from 0.2 to 2.2, with eight centers falling outside of the 90% confidence limits for an O/E ratio equaling 1.0. The O/E ratio for all centers has fallen by 14% over the 4.5-year period of this program (p = 0.06).Conclusions A large-scale, low-cost program of continuous quality improvement using risk-adjusted outcome is feasible. This program has been associated with a decrease in risk-adjusted operative mortality.