Comparative Effectiveness of Alternative Strategies for Monitoring Hospital Surgical Performance

摘要 与当前用于监测外科护理质量的方法相关的重要限制包括： (a)回顾性和偶发性（例如：每季度、每半年等）一种反馈方法， 当性能下降时和当医院意识到时之间的滞后;（B）临床上的小集群 使用当前的情景分析结构，可能无法发现有意义的不良业绩;（c）大多数 医疗保健实体愿意接受平均绩效，但如果绩效开始下降，则会做出反应 低于可接受的阈值。因此，可以缩短反馈时滞的替代方法， 改善对可能存在不佳围手术期护理流程的医院的检测，或激励 医院更积极主动地进行项目改进可以促进当前的质量改进 努力并为VHA带来实实在在的好处。本提案的总体目标是， 关于监测VA医院手术性能的新型替代方法的有效性数据， 当前的情景数据分析和反馈标准。具体目的是：（1）比较 （从工业界借用的统计过程控制方法）到偶发性的观测值与预期值之比 评估VA医院手术性能的方法;（2）评估30天的复合结局 死亡率、主要发病率和再次手术作为机构绩效下降的指标， 30-日死亡率或总发病率。这项工作将涉及医院级的观察设计， 接受普通住院患者的VA手术质量改进计划（VASQIP）数据， 2010年至2016年期间进行的血管、胸部、泌尿生殖系统、骨科、脊柱或神经外科手术。数据 将用于对这些用于监测VA的替代QI策略进行比较有效性分析 相对于当前30天死亡率的间歇性报告标准的医院手术性能，或 个别发病率。该项目是新颖的，因为它将是工业质量控制的第一个应用 VASQIP技术，将提供重要的现实世界的替代方法的比较数据， 评估医院绩效，并将在现有VASQIP的背景下评估此类方法 框架和基础设施，以促进未来的前瞻性评估和最终的实施。是 预计分析将证明这些替代方法可能具有重大价值， 医院的本地质量改进工作。为监测外科手术提供额外的方法 结果纳入VASQIP可能有显着的好处VHA和退伍军人通过早期认识到， 有潜在问题的围手术期护理过程的医院， 手术结果，降低纠正错误护理过程的成本，通过 早期识别和解决这些错误的过程，以及公众认为VA仍然存在 手术质量的全国领先者鉴于VHA目前的重点是确保在各级和 在所有护理环境中，这种替代方法也可能影响现有的质量改进， 手术之外的新项目或新举措。

Abstract Important limitations associated with current approaches for monitoring the quality of surgical care include: (a) the retrospective and episodic (e.g.: quarterly, bi-annually, etc.) approach to feedback which creates a time lag between when performance is declining and when the hospital is made aware; (b) small clusters of clinically meaningful poor performance may go of undetected using current episodic analytic structures; (c) most healthcare entities are willing to accept average performance, but will respond if performance starts to fall below an acceptable threshold. As such, alternative approaches that could shorten the time lag for feedback, improve the detection of hospitals with potentially suboptimal perioperative care processes, or inspire hospitals to be more proactive in programmatic improvement could enhance current quality improvement efforts and have tangible benefits for VHA. The overall goal of this proposal is to generate comparative effectiveness data on novel, alternative approaches for monitoring VA hospital surgical performance relative to the current standard of episodic data analysis and feedback. The specific aims are to: (1) compare the CUSUM (a statistical process control methodology borrowed from industry) to the episodic Observed-to-Expected approach for evaluating surgical performance at VA hospitals; (2) evaluate a composite outcome of 30-day mortality, major morbidity, and reoperation as an indicator of declining institutional performance relative to 30-day mortality or overall morbidity alone. This work will involve a hospital-level, observational design using VA Surgical Quality Improvement Program (VASQIP) data for patients who underwent inpatient general, vascular, thoracic, genitourinary, orthopedic, spine, or neurosurgical operations between 2010 and 2016. Data will be used to conduct a comparative effectiveness analysis of these alternative QI strategies for monitoring VA hospital surgical performance relative to the current standard of episodic reporting of 30-day mortality or morbidity individually. This project is novel because it will be the first application of industrial quality control techniques to VASQIP, will provide important real-world comparative data on alternative approaches for evaluating hospital performance, and will evaluate such approaches within the context of the existing VASQIP framework and infrastructure to facilitate future prospective evaluation and eventual implementation. It is anticipated the analyses will demonstrate these alternative approaches could have significant value for hospitals' local quality improvement efforts. Incorporating additional approaches for monitoring surgical outcomes into VASQIP could have notable benefits for VHA and Veterans through earlier recognition of hospitals with potentially problematic perioperative care processes that are associated with suboptimal post- operative outcomes, decreased costs for correcting errant care processes, decreased rates of morbidity through the earlier identification and resolution of such errant processes, and the public perception that the VA remains a national leader in surgical quality. Given the VHA's current focus on ensuring quality care at all levels and in all care settings, it is feasible such alternative approaches could also influence existing quality improvement programs or new initiatives outside of surgery as well.