Estimating the potential impact of regionalizing health care delivery based on volume standards versus risk-adjusted mortality rate.
Estimating the potential impact of regionalizing health care delivery based on volume standards versus risk-adjusted mortality rate.
复制标题
根据数量标准与风险调整死亡率来估计区域化医疗保健服务的潜在影响。
DOI：
10.1093/intqhc/mzm020
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发表时间：
2007
期刊：
影响因子：
--
通讯作者：
Dick,AndrewW
中科院分区：
文献类型：
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作者：
Glance,LaurentG;Osler,TurnerM;Mukamel,DanaB;Dick,AndrewW
目的研究基于风险调整死亡率的区域化是否会比基于手术量的区域化导致更好的人群结局。数据来源我们使用了来自医疗费用和利用项目的加州州住院患者数据库的二级数据。研究设计一项基于人群的回顾性队列研究，共有24.3万例患者接受了腹主动脉瘤手术，1998年至2000年在加州进行的冠状动脉搭桥手术或冠状动脉成形术。比较了四种区域化战略：（一）选择性转诊到高质量医院;（二）选择性转诊到高容量医院;（三）选择性避免低质量医院;（iv）选择性地避免低容量医院。主要发现选择性地转诊到高容量中心只会有适度的效果（死亡率相对降低2-20%）和极具破坏性（治疗这些疾病的医院数量减少70-99%）。据估计，选择性转诊至高质量中心可显著降低死亡率（50%），但也会造成严重破坏，超过80%的患者被重新转诊至高质量中心。选择性避开低容量医院不会提高死亡率，而选择性地避免低质量的医院估计会导致整体死亡率的小幅改善（2-6%），同时对患者转诊模式造成相对较小的干扰。在促进进一步努力使用数量截止值将保健服务区域化之前，
ObjectiveTo examine whether basing regionalization on risk-adjusted mortality would lead to better population outcomes than basing regionalization on procedure volume.Data sourceWe used secondary data from the California State Inpatient Database obtained from the Healthcare Costs and Utilization Project.Study designA population-based retrospective cohort study of 243 thousand patients who underwent either abdominal aortic aneurysm surgery, coronary artery bypass surgery or coronary angioplasty between 1998 and 2000 in California. Four regionalization strategies were compared: (i) selective referral to high-quality hospitals; (ii) selective referral to high-volume hospitals; (iii) selective avoidance of low-quality hospitals; (iv) selective avoidance of low-volume hospitals.Principal findingsSelective referral to high volume centers would be only moderately effective (2–20% relative reduction in mortality) and extremely disruptive (70–99% reduction in the number of hospitals treating these conditions). Selective referral to high quality centers was estimated to result in dramatic reduction in mortality (50%) but would also be highly disruptive with greater than 80% of the patients re-directed to high quality centers. Selective avoidance of low volume hospitals would not improve mortality, whereas selective avoidance of low quality hospitals was estimated to result in a small improvement in overall mortality (2–6%) while causing relatively minor disruptions in patient referral patterns.ConclusionEfforts to use volume standards as the basis for evidence-based hospital referrals should be re-evaluated by all stake-holders before promoting further efforts to regionalize health care delivery using volume cutoffs.