Adjusting surgical mortality rates for patient comorbidities: More harm than good?
Adjusting surgical mortality rates for patient comorbidities: More harm than good?
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DOI：
10.1067/msy.2002.126509
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发表时间：
2002-11-01
期刊：
影响因子：
3.8
通讯作者：
Wennberg, DE
中科院分区：
文献类型：
--
作者：
Finlayson, EVA;Birkmeyer, JD;Wennberg, DE
背景。医疗入院研究对使用索赔数据来调整先前存在的医疗状况（合并症）的有效性提出了质疑，但使用索赔数据中的合并症来调整高风险手术的风险调整死亡率的影响尚未得到很好的表征。本研究的目的是评估手术人群管理数据中合并症和死亡率之间的关系，并确定更好的风险调整方法。方法。使用国家医疗保险数据库（1994-1997），我们确定了择期腹主动脉瘤修复术（140,5 77）和胰十二指肠切除术（10, 530）的入院人数。我们计算了 5 种慢性疾病的相对死亡风险（根据年龄、性别、种族和入院敏锐度进行调整），这些慢性疾病（来自临床系列）已知会增加术后死亡风险，并且常用于基于索赔的风险调整模型。为了探索替代风险调整策略的潜在价值，我们使用从先前入院中确定的诊断代码检查了手术死亡率和合并症之间的关系。结果。总体而言，选择性腹主动脉瘤 (AAA) 修复术和胰十二指肠切除术的院内死亡率分别为 5.1% 和 10.4%。对于这两种手术，5 种合并症中有 3 种与死亡风险降低相关：既往心肌梗塞 (MI) [RR = 0.38；RR = 0.38；RR = 0.38]。 95% 置信区间 (CI)，AAA 为 0.33-0.43；相对比=0.38；胰十二指肠切除术 95% CI，0.21-0.69）、恶性肿瘤（RR = 0.67；AAA 95% CI，0.59-0.76；胰十二指肠切除术 RR = 0.74；95% CI，0.45-1.21）和糖尿病（RR = 0.76，95% CI，0.64-0.84 AAA；胰十二指肠切除术的 RR = 0.59，- 95% CI，0.49-0.69）。糖尿病（AAA 的 RR = 1.41；95% CI，1.25-1.59；胰十二指肠切除术的 RR = 0.94；95% CI，0.78-1.14）。结论：由于入院指标上编码的合并症似乎具有保护性，因此将其纳入比较手术表现的风险调整模型中可能会惩罚提供者对病情较重的患者进行护理。之前住院的情况对于风险调整可能更有用。
Background. Studies of medical admissions have questioned the validity of using claims data to adjust for preexisting medical conditions (comorbidities), but the impact of using comorbidities from claims data to risk-adjust mortality rates for high-risk surgery is not well characterized. The purpose of this study was to evaluate the relationship between comorbidities and mortality in administrative data in surgical populations and identify better risk-adjustment methods.Methods. Using the national Medicare database (1994-1997), we identified admissions for elective abdominal aortic aneurysm repair (140,5 77) and pancreaticoduodenectomy (10, 530). We calculated the relative risk of mortality (adjusted for age, sex, race, and admission acuity) for 5 chronic conditions that are known (from clinical series) to increase the risk of postoperative mortality and are commonly used in claims-based-risk-adjustment models. To explore the potential value of alternative risk-adjustment strategies, we examined relationships between surgical mortality and comorbidities using diagnosis codes identified from previous admissions.Results. Overall, in-hospital mortality for elective abdominal aortic aneurysm (AAA) repair and pancreaticoduodenectomy were 5.1% and 10.4%, respectively. For both procedures, 3 of the 5 comorbidities were associated with decreased risk of mortality: prior myocardial infarction (MI) [RR = 0.38; 95% confidence interval (CI), 0.33-0.43 for AAA; RR = 0.38; 95% CI, 0.21-0.69 for pancreaticoduodenectomy), malignancy (RR = 0.67; 95% CI, 0.59-0.76 for AAA; RR = 0.74; 95% CI, 0.45-1.21 for pancreaticoduodenectomy], and diabetes (RR = 0.76, 95% CI, 0.64-0.84 for AAA; RR = 0.59,- 95% CI, 0.49-0.69 for pancreaticoduodenectomy). Using comorbidities identified from prior admissions increased the mortality risk estimates for prior MI (RR = 1.22; 95% CI, 1.08-1.38 for AAA; RR = 0.80, 95% CI, 0.49-1.30 for pancreaticoduodenectomy) and diabetes (RR = 1.41; 95% CI, 1.25-1.59 for AAA; RR = 0.94; 95% CI, 0.78-1.14 for pancreaticoduodenectomy).Conclusions. Because comorbidities coded on the index admission appear protective, incorporating them in risk-adjustment models for studies comparing surgical performance may penalize providers for taking. care of sicker patients. When available, comorbidity information from prior hospitalizations may be more useful for risk adjustment.