Optimizing the Risk-Adjusted CUSUM for Monitoring Hospital Non-cardiac Perioperative Outcomes

国家手术质量改进(QI)计划，如退伍军人事务部(VA)手术质量 改进计划(VASQIP)与美国外科医师学会国家外科质量 改进计划(ACS NSQIP)，收集、分析并为医院提供机构级的、经过风险调整的 以间歇性(例如，季度)方式显示围手术期发病率和死亡率数据。医院反过来使用 这些数据为他们当地的QI努力提供了信息。虽然这种时断时续的反馈方法在几乎所有人中都是惯例 国家外科QI计划，它与两个重要的限制有关：1)在 医院业绩正在下降，当季度数据结束时提供通知 确认期；2)检测可能发生的不良事件的潜在有意义的群集的有限能力 不认识时断时续的评估策略。一个潜在的替代分析策略，可以 补充和加强目前外科手术QI的方法是累积和(CUSUM)。累积和是 一种统计过程控制方法，已在工业设置中用于提供实时 监控生产过程的质量。在医疗保健中，累积和被用来确定 当结果变化接近不可接受的水平并且非常适合于检测相对较小的时， 然而，随着时间的推移，给定结果会发生持久的变化。它目前由器官联合网络使用 共享成员资格和专业标准委员会，一个监管移植手术的机构 美国，用于实时监测医院级移植后患者和移植物的长期存活情况。在……里面 此外，我们小组正在进行的工作表明，累积和始终提供早期、有意义的 以绩效为基础的机构对围手术期结果的反馈。这项提案的总体目标是 是在我们之前工作的基础上，探索如何优化累积和，以便在国家外科QI中使用 能够及早、准确地发现业绩不佳的医院的计划。使用国家VASQIP 数据，我们的目标是：1)评估给定季度的多个CUSUM信号是否减少了错误 医院检测阳性；2)探索连续运行的累积和是否(在多个季度内) 减少假阳性医院检测；3)描述与假阳性和假阳性相关的医院因素 负累积和信号。这项工作将有助于为未来对累积和和的预期评价提供信息 VASQIP的最终实施。利用VASQIP的现有基础设施为机构提供 有了更多的实时、可操作的数据，最终可能会检测到以前未被重视的 次优护理流程，使患者免于可预防的发病率和/或死亡率。

National surgical quality improvement (QI) programs, such as the Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP) and the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), collect, analyze, and provide hospitals with institution-level, risk-adjusted data on perioperative morbidity and mortality in an episodic (e.g., quarterly) fashion. Hospitals in turn use these data to inform their local QI efforts. While this episodic approach to feedback is a convention in nearly all national surgical QI programs, it is associated with two important limitations: 1) a time lag between when hospital performance is declining and when notification is provided at the end of the quarterly data ascertainment period; 2) a limited ability to detect potentially meaningful clusters of adverse events that may go unrecognized with episodic evaluation strategies. One potential alternative analytic strategy that could supplement and enhance current approaches to surgical QI is the cumulative sum (CUSUM). The CUSUM is a statistical process control method that has been utilized in the industrial setting to provide real-time monitoring of the quality of production processes. In health care, the CUSUM has been used to ascertain when outcome variation is approaching an unacceptable level and is well-suited for detecting relatively small, yet persistent, changes in a given outcome over time. It is currently used by the United Network for Organ Sharing Membership and Profession Standard Committee, a regulatory body for transplant surgery in the United States, for monitoring hospital-level post-transplant patient and graft long-term survival in real-time. In addition, our group’s ongoing work has shown the CUSUM consistently provides early, meaningful, performance-based institutional feedback regarding perioperative outcomes. The overall goal of this proposal is to build upon our prior work by exploring how to optimize the CUSUM for use within national surgical QI programs to enable early and accurate detection of hospitals with poor performance. Using national VASQIP data, our goals are to: 1) evaluate whether multiple CUSUM signals in a given quarter decreases false positive hospital detection; 2) explore whether a continuously running CUSUM (over multiple quarters) decreases false positive hospital detection; 3) describe hospital factors associated with false positive and false negative CUSUM signaling. This work will help to inform a future prospective evaluation of the CUSUM and eventual implementation withing VASQIP. Leveraging VASQIP’s existing infrastructure to provide institutions with more real-time, actionable data could ultimately result in the detection of previously unappreciated suboptimal care processes and save patients from preventable morbidity and/or mortality.