Multicentre observational study of performance variation in provision and outcome of emergency appendicectomy
Multicentre observational study of performance variation in provision and outcome of emergency appendicectomy
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DOI：
10.1002/bjs.9201
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发表时间：
2013-08-01
影响因子：
9.6
通讯作者：
Pinkney, T.
中科院分区：
文献类型：
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作者：
Bhangu, A.;Richardson, C.;Pinkney, T.
背景：识别实践中的差异是实现服务标准化和确定可靠的质量标志的关键一步。本研究旨在探讨急诊阑尾切除手术方式与结果的差异。方法：本研究于2012年5月至6月期间进行了一项多中心、学员主导、方案驱动的前瞻性观察队列研究。令人感兴趣的主要结果是正常的组织病理学比率；次要结果是腹腔镜术和30天不良事件发生率。分析包括漏斗图和二元Logistic回归模型，以确定患者和医院相关的预后预测因素。结果：来自95个中心的3326名患者纳入其中。663%的患者接受了最初的腹腔镜手术(在研究期间进行了25次以上的阑尾切除术的中心：87%-100%)。有206%的患者切除了组织学上正常的阑尾(进行了25次以上手术的患者比例为3.3-36.8%)。漏斗图分析显示，22个中心的腹腔镜率低于平均值的三个标准差。更高的中心容量、会诊医生和日间手术独立地与增加使用腹腔镜术有关，这反过来又与减少30天的发病率有关(根据疾病严重程度进行调整)。日间手术进一步降低了正常的阑尾切除率。量的增加是以较高的阴性率为代价的，而低阴性率是以较高的穿孔率为代价的。结论：这项研究揭示了不同医院之间实践模式和结果的极大差异。导致这一差异的组织因素已经确定，并应加以处理，以提高业绩。
Background: Identification of variation in practice is a key step towards standardization of service and determination of reliable quality markers. This study aimed to investigate variation in provision and outcome of emergency appendicectomy.Methods: A multicentre, trainee-led, protocol-driven, prospective observational cohort study was performed duringMay and June 2012. The main outcome of interest was the normal histopathology rate; secondary outcomes were laparoscopy and 30-day adverse event rates. Analysis included funnel plots and binary logistic regression models to identify patient-and hospital-related predictors of outcome.Results: A total of 3326 patients from 95 centres were included. An initial laparoscopic approach was performed in 66 3 per cent of patients (range in centres performing more than 25 appendicectomies over the study period: 8 7-100 per cent). A histologically normal appendix was removed in 20 6 per cent of patients (range in centres performing more than 25 procedures: 3 3-36 8 per cent). Funnel plot analysis revealed that 22 centres fell below three standard deviations of the mean for laparoscopy rates. Higher centre volume, consultant presence in theatre and daytime surgery were independently associated with an increased use of laparoscopy, which in turn was associated with a reduction in 30-day morbidity (adjusted for disease severity). Daytime surgery further reduced normal appendicectomy rates. Increasing volume came at the cost of higher negative rates, and low negative rates came at the cost of higher perforation rates.Conclusion: This study reveals the extremely wide variation in practice patterns and outcomes among hospitals. Organizational factors leading to this variation have been identified and should be addressed to improve performance.