A decade's experience with quality improvement in cardiac surgery using the Veterans Affairs and Society of Thoracic Surgeons national databases
A decade's experience with quality improvement in cardiac surgery using the Veterans Affairs and Society of Thoracic Surgeons national databases
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DOI：
10.1097/00000658-200110000-00006
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发表时间：
2001-10-01
影响因子：
9
通讯作者：
McDonald, G
中科院分区：
文献类型：
--
作者：
Grover, FL;Shroyer, ALW;McDonald, G
目的回顾美国退伍军人事务部（VA）和美国胸外科医师协会（STS）近10年来的国家级数据库，评价两者的异同，评价其作为质量改进工具的作用，并评估其促进心脏外科护理质量改善的潜力。背景资料概述VA制定了一项强制性风险-1987年调整数据库，以监测所有VA医疗中心的心脏手术结局。在1989年的STS开发了一个自愿的风险调整数据库，以帮助成员评估质量和成果，在他们的个人计划，以促进改善质量的carry.Methods一个简短的数据表，对每一个退伍军人在每个VA医疗中心进行操作，完成和传输电子分析未调整和风险调整的死亡和并发症，以及住院时间。然后将保密的半年度报告分发给每个项目的临床团队和相关管理人员。这些报告也由国家质量监督委员会审查。因此，VA数据在当地用于质量改进，在国家一级用于质量监督。每半年将每例患者的STS数据集（217个核心字段和255个扩展字段）传输至杜克临床研究所（DCRI）进行入库、分析和分发。针对未调整和调整的手术死亡和并发症以及冠状动脉旁路移植术（CABG）、瓣膜手术和瓣膜/CABG手术的住院时间，生成了地区和国家汇总比较的临床试验机构特定报告。两个数据库都使用逻辑回归建模方法。两个数据库中还收集了关键护理过程的数据。研究项目经常进行使用每个database.Results超过74，000和160万心脏手术患者已进入VA和STS数据库，分别。两个数据库中预测CABG手术死亡的风险因素非常相似，大多数风险因素的比值比也非常相似。一个主要的区别是，VA是99%的男性，STS是71%的男性。这两个数据库都显示，在过去十年中，尽管患者的风险因素增加，但风险调整后的手术死亡率显著降低。观察到的预期死亡率的比率从1.05下降到0.9的VA和从1.5到0.9的STS.Conclusion看来，这些程序提供的风险调整后的数据对本地性能的常规反馈提高了认识，并导致自我检查和自我评估，这反过来又提高了质量和成果。这种一般质量改进模板应考虑应用于心脏手术以外的其他环境。
Objective To review the Department of Veteran Affairs (VA) and the Society of Thoracic Surgeons (STS) national databases over the past 10 years to evaluate their relative similarities and differences, to appraise their use as quality improvement tools, and to assess their potential to facilitate improvements in quality of cardiac surgical care.Summary Background Data The VA developed a mandatory risk-adjusted database in 1987 to monitor outcomes of cardiac surgery at ail VA medical centers. In 1989 the STS developed a voluntary risk-adjusted database to help members assess quality and outcomes in their individual programs and to facilitate improvements in quality of care.Methods A short data form on every veteran operated on at each VA medical center is completed and transmitted electronically for analysis of unadjusted and risk-adjusted death and complications, as well as length of stay. Masked, confidential semiannual reports are then distributed to each program's clinical team and the associated administrator. These reports are also reviewed by a national quality oversight committee. Thus, VA data are used both locally for quality improvement and at the national level with quality surveillance. The STS dataset (217 core fields and 255 extended fields) is transmitted for each patient semiannually to the Duke Clinical Research Institute (DCRI) for warehousing, analysis, and distribution. Site-specific reports are produced with regional and national aggregate comparisons for unadjusted and adjusted surgical deaths and complications, as well as length of stay for coronary artery bypass grafting (CABG), valvular procedures, and valvular/CABG procedures. Both databases use the logistic regression modeling approach. Data for key processes of care are also captured in both databases. Research projects are frequently carried out using each database.Results More than 74,000 and 1.6 million cardiac surgical patients have been entered into the VA and STS databases, respectively. Risk factors that predict surgical death for CABG are very similar in the two databases, as are the odds ratios for most of the risk factors. One major difference is that the VA is 99% male, the STS 71% male. Both databases have shown a significant reduction in the risk-adjusted surgical death rate during the past decade despite the fact that patients have presented with an increased risk factor profile. The ratio of observed to expected deaths decreased from 1.05 to 0.9 for the VA and from 1.5 to 0.9 for the STS.Conclusion It appears that the routine feedback of risk-adjusted data on local performance provided by these programs heightens awareness and leads to self-examination and self-assessment, which in turn improves quality and outcomes. This general quality improvement template should be considered for application in other settings beyond cardiac surgery.