Effect of Subjective Preoperative Variables on Risk-Adjusted Assessment of Hospital Morbidity and Mortality
Effect of Subjective Preoperative Variables on Risk-Adjusted Assessment of Hospital Morbidity and Mortality
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DOI：
10.1097/sla.0b013e31819eda21
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发表时间：
2009-04-01
影响因子：
9
通讯作者：
Hall, Bruce Lee
中科院分区：
文献类型：
--
作者：
Cohen, Mark E.;Bilimoria, Karl Y.;Hall, Bruce Lee
目的：研究美国麻醉医师协会身体状况分类 (ASA) 和术前功能健康状况 (FHS) 变量对手术质量风险调整估计的影响，并评估某些医院的分类是否夸大。背景：ASA 和 FHS 对手术质量风险调整比较有影响。然而，由于 ASA 和 FHS 是主观的，因此它们可能会被夸大，使患者看起来比实际情况更严重，并将病情更严重的患者群体归功于医院。方法：我们在 2006 年至 2007 年期间，在 170 家医院中确定了参加美国外科医生学会国家手术质量改进计划 (ACS NSQIP) 的 28,75 1 名结直肠手术患者。针对包含和不包含包含在内的发病率和死亡率开发了 Logistic 回归模型ASA 和 FHS。比较不同模型的医院质量排名。结果：发病率和死亡率分别为24.3%和3.9%。分别。 ASA I 至 V 级患者的百分比分别为 3.3%、46.4%、41.5%。独立或部分或完全依赖的人分别为8.3%和0.7%，分别为89.2%、7.2%和3.6%。包含 ASA 和 FHS 的模型比不包含这两个变量的模型表现出稍微更好的拟合度（Hosmer-Lemshow 统计量）和辨别力（c 统计量），尽管差异的大小与机会一致。存在不一致的证据表明 ASA 和 FHS 分配不当。结论：当 ASA 和 FHS 存在时与不存在时模型质量略有改善，表明它们对评估术前风险的严重程度做出了独特的贡献。由于几乎没有迹象表明这些主观变量会受到严重程度的机构偏差的影响，因此将它们用于评估风险调整后的手术质量是适当的。有必要定期监测 ASA 状态的不当膨胀。
Objective: To examine the influence of American Society of Anesthesiologists Physical Status Classification (ASA) and preoperative Functional Health Status (FHS) variables on risk-adjusted estimates of surgical quality and to assess whether classifications are inflated at some hospitals.Background: ASA and FHS are influential in risk-adjusted comparisons of surgical quality. However, because ASA and FHS are subjective they can be inflated, making patients appear more ill than they actually are, and crediting hospitals for a sicker patient population.Methods: We identified 28,75 1 colorectal surgery patients at 170 hospitals participating in the American College of Surgeon's National Surgical Quality Improvement Program (ACS NSQIP) during 2006 to 2007. Logistic regression models were developed for morbidity and mortality with and without inclusion of ASA and FHS. Hospital quality rankings from the different models were compared.Results: Morbidity and mortality rates were 24.3% and 3.9%. respectively. Percents of patients in ASA classes I through V were 3.3%, 46.4%, 41.5%. 8.3%, and 0.7% and that were independent or partially or totally dependent were 89.2%, 7.2% and 3.6%, respectively. Models that included ASA and FHS exhibited slightly better fit (Hosmer-Lemshow statistic) and discrimination (c-statistic) than models without both these variables, though magnitudes of differences were consistent with chance. There was inconsistent evidence for improper assignment of ASA and FHS.Conclusions: The small improvements in model quality when both ASA and FHS are present versus absent, suggest that they make a unique contribution to assessing severity of preoperative risk. With little indication that these subjective variables are subject to an important level of institutional bias, it is appropriate that they be used to assess risk-adjusted surgical quality. Periodic monitoring for inappropriate inflation of ASA status is warranted.