Identifying High-Quality Bariatric Surgery Centers: Hospital Volume or Risk-Adjusted Outcomes?
Identifying High-Quality Bariatric Surgery Centers: Hospital Volume or Risk-Adjusted Outcomes?
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DOI：
10.1016/j.jamcollsurg.2009.09.009
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发表时间：
2009-12-01
影响因子：
5.2
通讯作者：
Birkmeyer, John D.
中科院分区：
文献类型：
--
作者：
Dimick, Justin B.;Osborne, Nicholas H.;Birkmeyer, John D.
背景：支付者和专业组织正在扩大减肥手术的认证和“卓越中心”计划。大多数程序依赖于程序量，而不是直接测量结果。我们试图确定是否风险调整的结果或医院的容量更好地预测未来的医院发病率与减肥surgery.Study Design：我们确定了所有的病人谁接受胃旁路术在纽约州住院病人数据库（n = 32,381例患者，n = 105家医院）。使用先前确认的诊断和程序代码组合确定发病率。我们首先计算了2年期间（2003年至2004年）每家医院的风险调整后的发病率和数量。然后，我们确定了医院水平的变化的比例解释每一个措施，使用分层建模技术。最后，我们比较了每种措施的能力，以预测未来的性能，评估与风险调整后的发病率，在未来2年（2005年至2006年）。结果：风险调整后的发病率解释83%的未来医院水平的变化，发病率相比，只有21%的医院容量。当比较“最佳”与“最差”医院四分位数时，风险调整后的发病率预测未来表现的差异超过4倍（1.7% vs 7.2%;比值比[OR]：4.5; 95%CI，3.5 - 5.9）。医院容量预测只有两倍的差异（2.5%与4.5%; OR：1.9; 95%CI，1.5至2.4）从最好的到最差的quartile.CONCLUSIONS：风险调整后的发病率是更好的比医院容量在预测未来的表现与减肥手术。认证和卓越中心项目不应关注数量，而应更多地关注直接衡量结果。（美国科尔外科杂志2009;209：702-706。(C)2009年由Elsevier Inc.出版美国外科医生学会（American College of Surgeons）
BACKGROUND: Payers and professional organizations are expanding accreditation and "centers of excellence" programs in bariatric surgery. Rather than directly measuring Outcomes, most programs rely on procedure volume. We sought to determine whether risk-adjusted outcomes or hospital volume were better at predicting future hospital morbidity with bariatric surgery.STUDY DESIGN: We identified all patients who underwent gastric bypass in the New York State Inpatient database (n = 32,381 patients, n = 105 hospitals). Morbidity was ascertained using a previously validated combination of diagnostic and procedure codes. We first calculated the risk-adjusted morbidity and volume at each hospital during a 2-year period (2003 to 2004). We then ascertained the proportion of hospital-level variation explained by each measure using hierarchical modeling techniques. Finally, we compared the ability of each measure to predict future performance, as assessed with risk-adjusted morbidity, in the next 2 years (2005 to 2006).RESULTS: Risk-adjusted morbidity explained 83% of future hospital-level variation in morbidity compared with only 21% for hospital volume. When comparing the "best" with the "worst" hospital quartiles, risk-adjusted morbidity predicted a more than fourfold difference in future performance (1.7% versus 7.2%; odds ratio [OR]: 4.5; 95% Cl, 3.5 to 5.9). Hospital volume predicted only a twofold difference (2.5% versus 4.5%; OR: 1.9; 95% Cl, 1.5 to 2.4) from the best to worst quartile.CONCLUSIONS: Risk-adjusted morbidity is much better than hospital volume at predicting future performance with bariatric surgery. Rather than focusing on volume, accreditation and centers of excellence programs should focus more on directly measuring outcomes. (J Am Coll Surg 2009;209: 702-706. (C) 2009 Published by Elsevier Inc. on behalf of the American College of Surgeons)