What is the best way to estimate hospital quality outcomes? A simulation approach.
What is the best way to estimate hospital quality outcomes? A simulation approach.
复制标题
评估医院质量结果的最佳方法是什么？
DOI：
10.1111/j.1475-6773.2012.01382.x
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发表时间：
2012
影响因子：
3.4
通讯作者：
Dimick,Justin
中科院分区：
文献类型：
--
作者：
Ryan,Andrew;Burgess,James;Strawderman,Robert;Dimick,Justin
目的通过蒙特卡罗模拟实验检验医院死亡率质量替代估计量的准确性。数据来源数据被模拟以创建入院水平分析数据集。通过比较分布参数（例如，30天死亡率的平均值和标准差，医院样本量）与急性心肌梗死（AMI）住院患者的医疗保险数据中观察到的相同参数。研究设计我们进行了Monte Carlo模拟实验，其中真实质量已知，以测试观察超过预期估计量，风险标准化死亡率（RSMR），Dimick和Staiger（DS）估计量，分层泊松估计量和移动平均估计量，使用AMI的医院30天死亡率作为结果。评估所有医院以及小型、中型和大型医院的估计器准确性。数据提取方法数据进行模拟。主要发现在测试的结果估计器的准确性中观察到显着且实质性的变化。DS估计是最准确的所有医院和小医院使用两个准确性标准（均方根误差和比例的医院正确分类成quintiles）.ConclusionsThe死亡率估计目前使用的医疗保险的公共质量报告，RSMR，已被证明是不准确的DS估计，虽然幅度的差异不大。在使用当前医院数据对我们的发现进行测试和验证之前，CMS应该重新考虑使用RSMR公开报告死亡率的决定。
ObjectiveTo test the accuracy of alternative estimators of hospital mortality quality using a Monte Carlo simulation experiment.Data SourcesData are simulated to create an admission‐level analytic dataset. The simulated data are validated by comparing distributional parameters (e.g., mean and standard deviation of 30‐day mortality rate, hospital sample size) with the same parameters observed in Medicare data for acute myocardial infarction (AMI) inpatient admissions.Study DesignWe perform a Monte Carlo simulation experiment in which true quality is known to test the accuracy of the Observed‐over‐Expected estimator, the Risk Standardized Mortality Rate (RSMR), the Dimick and Staiger (DS) estimator, the Hierarchical Poisson estimator, and the Moving Average estimator using hospital 30‐day mortality for AMI as the outcome. Estimator accuracy is evaluated for all hospitals and for small, medium, and large hospitals.Data Extraction MethodsData are simulated.Principal FindingsSignificant and substantial variation is observed in the accuracy of the tested outcome estimators. The DS estimator is the most accurate for all hospitals and for small hospitals using both accuracy criteria (root mean squared error and proportion of hospitals correctly classified into quintiles).ConclusionsThe mortality estimator currently in use by Medicare for public quality reporting, the RSMR, has been shown to be less accurate than the DS estimator, although the magnitude of the difference is not large. Pending testing and validation of our findings using current hospital data, CMS should reconsider the decision to publicly report mortality rates using the RSMR.