The Influence of Procedure Volumes and Standardization of Care on Quality and Efficiency in Total Joint Replacement Surgery
The Influence of Procedure Volumes and Standardization of Care on Quality and Efficiency in Total Joint Replacement Surgery
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DOI：
10.2106/jbjs.i.01477
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发表时间：
2010-11-17
影响因子：
5.3
通讯作者：
Auerbach, Andrew D.
中科院分区：
文献类型：
--
作者：
Bozic, Kevin J.;Maselli, Judith;Auerbach, Andrew D.
背景 外科医生和医院手术量与全关节置换术临床结果之间的关系长期以来引发了关于护理区域化的争论。与此同时，许多政策举措都致力于通过激励外科医生遵守循证护理流程来提高质量。本研究的目的是评估外科医生手术量、医院手术量和护理标准化对下肢全关节置换术短期术后结果和资源利用率的独立贡献。使用来自 312 家医院的 3421 名医生在两年内输入 Perspective 数据库的数据，对 182,146 名连续接受初次全关节置换术的患者进行了遵守循证护理流程的定义是在围手术期进行适当的抗生素预防、β 受体阻滞和静脉血栓栓塞预防。患者结局包括死亡率、住院时间、出院处置、手术并发症、再入院和再次手术。出院后的前 30 天 使用分层模型来估计医院和外科医生的手术量和流程标准化对个体和组合手术结果以及住院时间的影响结果 在多变量模型中调整后，较高的外科医生手术量与较低的并发症风险、较低的再入院和再手术率、较短的住院时间以及较高的出院回家可能性相关较高的医院手术量与较低的死亡率风险、较低的再入院风险以及较高的出院回家可能性相关。流程标准化的影响是巨大的，最大限度地提高了依从性基于证据的护理流程可改善临床结果并缩短住院时间，与医院或外科医生的手术量无关 结论 虽然外科医生和医院的手术量无疑与全关节置换术中的患者结果相关，但流程标准化也与护理质量和效率的提高密切相关。个体护理流程与患者结果之间的确切关系尚未确定，但是，我们的研究结果表明，流程标准化可以帮助提供者优化全关节置换术的质量和效率，与医院或外科医生的手术量无关
Background The relationship between surgeon and hospital procedure volumes and clinical outcomes in total joint arthroplasty has long fueled a debate over regionalization of care At the same time, numerous policy initiatives are focusing on improving quality by incentivizing surgeons to adhere to evidence-based processes of care The purpose of this study was to evaluate the independent contributions of surgeon procedure volume, hospital procedure volume, and standardization of care on short term postoperative outcomes and resource utilization in lower extremity total joint arthroplastyMethods An analysis of 182,146 consecutive patients who underwent primary total joint arthroplasty was performed with use of data entered into the Perspective database by 3421 physicians from 312 hospitals over a two-year period Adherence to evidence based processes of care was defined by administration of appropriate perioperative antibiotic prophylaxis, beta blockade, and venous thromboembolism prophylaxis Patient outcomes included mortality, length of hospital stay, discharge disposition, surgical complications, readmissions, and reoperations within the first thirty days after discharge Hierarchical models were used to estimate the effects of hospital and surgeon procedure volume and process standardization on individual and combined surgical outcomes and length of stayResults After adjustment in multivariate models, higher surgeon volume was associated with lower risk of complications, lower rates of readmission and reoperation, shorter length of hospital stay, and higher likelihood of being discharged home Higher hospital volume was associated with lower risk of mortality, lower risk of readmission, and higher likelihood of being discharged home The impact of process standardization was substantial, maximizing adherence to evidence based processes of care resulted in improved clinical outcomes and shorter length of hospital stay, independent of hospital or surgeon procedure volumeConclusions Although surgeon and hospital procedure volumes are unquestionably correlated with patient outcomes in total joint arthroplasty process standardization is also strongly associated with improved quality and efficiency of care The exact relationship between individual processes of care and patient outcomes has not been established, however, our findings suggest that process standardization could help providers optimize quality and efficiency in total joint arthroplasty, independent of hospital or surgeon volume