The evaluation of treatment when center-specific selection criteria vary with respect to patient risk
The evaluation of treatment when center-specific selection criteria vary with respect to patient risk
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DOI：
10.1111/j.1541-0420.2005.00358.x
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发表时间：
2005-12-01
期刊：
影响因子：
1.9
通讯作者：
Peterson, ED
中科院分区：
文献类型：
--
作者：
DeLong, ER;Coombs, LP;Peterson, ED
许多医疗保健标准是基于各种治疗策略或过程的证明效果。与药物治疗不同，这些策略或过程不一定要经过严格的临床试验，它们的益处通常是通过观察数据来评估的。为了评估此类医疗过程对患者预后的影响，不仅要考虑风险调整，而且“中心效应”也是一个重要的、经常被忽视的考虑因素。护理的质量和使用某些治疗或过程的倾向都因中心而异。在风险调整的背景下，需要解决中心内结果的诱导相似性，以及中心混淆的可能性。此外，治疗策略的中心特异性选择标准可能因患者风险而异。由于这些考虑，重要的是要充分区分治疗或策略的中心内效应和跨中心效应，后者更多地与中心表现有关。本文的主要目的是探索和扩展目前处理二分类结果的中心混淆的方法，主要是针对根据患者风险进行选择的情况。仿真研究比较了几种不同分析方法的结果，并提供了在评估过程有效性时考虑风险和中心混淆的重要性的证据。本文还介绍了旁路手术后早期拔管的效果。
Many standards of medical care are based on the demonstrated effects of various treatment strategies or processes. Unlike pharmacological treatments, these strategies or processes are not necessarily subjected to rigorous clinical trials and their benefit is frequently assessed from observational data. For evaluating the influence of such medical processes on patient outcomes, not only is risk adjustment an issue, but also the "center effect" represents an important, often overlooked consideration. Both the quality of care and the tendency to use certain treatments or processes vary from one center to another. The induced similarity in outcomes within center, as well as the potential for confounding by center, needs to be addressed within the context of risk adjustment. In addition, center-specific selection criteria for a treatment strategy can vary with respect to patient risk. Because of these considerations, it is important to adequately separate the within-center effects of the treatment or strategy from the across-center effects, which relate more to center performance. The primary objective of this article is to explore and extend current methods of dealing with center confounding for dichotomous outcomes, primarily for the situation where selection on the basis of patient risk can vary from center to center. A simulation study compares results from several different analytic methods and provides evidence for the importance of considering confounding due to both risk and center when evaluating the effectiveness of a process. An example that examines the effect of early extubation after bypass surgery is also presented.