MEASURING AND IMPROVING QUALITY: CAROTID ENDARTERECTOMY

颈动脉内膜切除术是一种外科手术，通常在 老年人预防中风。它的年发病率正在迅速上升， 1991年至1994年，全国增长了61%。过去的研究表明 提示与此程序相关的重大质量问题， 包括：选择不合适的外科候选人，高 社区研究的并发症发生率与此相反 提供商数量和并发症之间的关系，以及实质性 使用率的种族差异。最近的研究产生了许多新的 关于这一手术的疗效的数据，但关于质量的新数据很少 关心。 我们建议调查颈动脉内膜切除术的护理质量。 一项回顾性、多队列、两阶段研究，测量 适当性、风险调整后的并发症(死亡、中风和 心肌梗死)与特定外科手术的关系 关注结果的过程。在第一阶段，我们将研究患者 在7家合作医院接受治疗。在第二阶段，我们将 进行2项平行调查。我们将研究一个大型的、分层的 从纽约州各地随机抽取了约8000例医疗保险病例， 一个足够大的样本，足以建立风险调整后的稳健模型 围手术期并发症。我们将审查适当性、风险- 调整后的结果，以及手术护理过程。试图 作为最佳手术实践的特征，我们将评估 特定的手术护理过程与低发生率相关。 风险调整的围手术期并发症。此外，我们还将探索 医院和外科医生数量与风险调整的关系 围手术期并发症。我们还将评估两国关系 在种族和适当性之间。 在第二阶段的第二部分，我们将设计、实施和评估 在7个协作会议上进行的一系列质量改进干预 医院。在外科医生的积极参与下 颈动脉内膜切除术在这些机构，我们将检查阶段 1适当性数据。我们将考察它们之间的差异 合作医院在外科护理过程中的阶段显示 2与改善风险调整的围手术期结局有关。 我们将在每家医院确定哪些医院有改进的机会 患者选择的适当性和治疗的有效性 手术过程的护理、干预以改善和评估影响 这些干预措施。

Carotid endarterectomy is a surgical procedure commonly performed among the elderly to prevent stroke. Its annual incidence is rising rapidly, up 61 percent nationally between 1991 and 1994. Past research has suggested significant quality problems relating to this procedure, including: the selection of inappropriate surgical candidates, high rates of complications in community-based studies, an inverse relationship between provider volume and complications, and substantial racial disparities in use rates. Recent studies have produced much new data on the efficacy of this operation but few new data on quality of care. We propose to investigate quality of care in carotid endarterectomy in a retrospective, multiple cohort, 2-phase study, measuring appropriateness, risk-adjusted complications (death, stroke, and myocardial infarction), and the relationship of specific surgical processes of care to outcomes. In the phase 1, we will study patients treated in a group of 7 collaborating hospitals. In phase 2, we will conduct 2 parallel investigations. We will study a large, stratified random sample of about 8000 Medicare cases from across New York State, a sample large enough to build robust models of risk-adjusted perioperative complications. We will examine appropriateness, risk- adjusted outcomes, and surgical processes of care. Attempting to characterize best surgical practices, we will assess the extent to which specific surgical processes of care are associated with low rates of risk-adjusted perioperative complications. In addition, we will explore the relationship of hospital and surgeon volume to risk-adjusted perioperative complications. We will also assess the relationship between race and appropriateness. In the second part of phase 2, we will design, conduct, and evaluate a series of quality improvement interventions at the 7 collaborating hospitals. With the active participation of the surgeons who perform carotid endarterectomy at these institutions, we will examine the phase 1 data on appropriateness. We will examine differences among collaborating hospitals in the surgical processes of care shown in Phase 2 to be associated with improved risk-adjusted perioperative outcomes. We will determine at each hospital where opportunities exist to improve both the appropriateness of patient selection and the effectiveness of surgical processes of care, intervene to improve, and assess the impact of those interventions.