Comparative effectiveness of real-time and episodic hospital surgical performance evaluation

项目摘要/摘要 当代手术质量改进(QI)计划为医院提供阶段性反馈。主要有两种 与此方法相关的限制。第一个是数据抽象、分析和后续操作所需的时间 反馈在医院性能下降和医院性能下降之间产生了固有的时间延迟 接收此信息。第二个问题是，目前的情景分析方法无法明确地解释 时间的影响是可变的(即：在短时间内发生一系列事件)。插曲数据放在 医院的本地QI团队处于劣势，因为他们对业绩下降的反应必须是被动的，而不是 积极主动。此外，在性能下降和这种下降之间的时间间隔内接受治疗的患者 可能面临暴露于次优围手术期护理过程的风险。累计总和 (累积和)是一种工业统计过程控制方法，传统上用于监控产品的质量 并确保该过程高效、有效和充分发挥其潜力。积和法非常适合 用于确定罕见结果随时间的变化，对多个统计测试具有弹性，并明确说明 时间作为一个变量的影响。它已被用于医疗保健评估，并被证明提供了早期的、有意义的 基于绩效的反馈。本提案的目标是比较经风险调整、时间到- 事件累积和用于早期检测在30天发病率和死亡率方面表现异常的医院 相对于退伍军人管理局手术质量所使用的间歇性观察到预期(O-E)方法的标准 改进计划(VASQIP)和美国外科医师学会国家外科质量改进 程序。利用国家VASQIP数据，我们打算：1.)评估累积和是否识别出类似的异常值 与O-E方法相关的医院，并比较识别异常值的时间差异；估计一下 与O-E医院相比，使用CUSUM的高危外科手术次数和术后患者天数 绩效评估。这项提案的数据将为未来对累积和的未来评估提供参考 退伍军人管理局现有的外科QI框架和基础设施，最终目标是整合CUSUM 到VASQIP报告中。向医院提供更及时的数据将有利于当地的QI努力，并可能转变 从对事件数据的被动反应转向基于更实时的评估的主动方法 性能。在绩效下降时，而不是在绩效下降时，确定纠正错误护理流程的机会 已经达到了不可接受的水平，这可能会减少面临意外后果风险的手术患者的数量， 减少与纠正错误的护理过程和治疗潜在的可预防的发病率相关的成本，以及 让外科护理更安全。

Project Summary/Abstract Contemporary surgical quality improvement (QI) programs provide hospitals with episodic feedback. There are two main limitations associated with this approach. The first is the time required for data abstraction, analysis, and subsequent feedback creating a built-in time lag between when a hospital is having a decrement in performance and when the hospital receives this information. The second is the inability of current episodic analytic methods to explicitly account for the impact of time as variable (i.e.: the occurrence of a cluster of events in a short period of time). Episodic data put hospitals' local QI teams at a disadvantage because their response to declining performance must be reactive rather than proactive. Furthermore, patients treated in the interval between when performance is declining and when this decrement is appreciated are potentially at risk for exposure to suboptimal perioperative care processes. The cumulative sum (CUSUM) is an industrial statistical process control method traditionally used for monitoring the quality of a production process and for ensuring that process is operating efficiently, effectively, and at full potential. The CUSUM is well-suited for ascertaining variation over time for rare outcomes, is resilient to multiple statistical testing, and explicitly accounts for the impact of time as a variable. It has been used for health care evaluation and shown to provide early, meaningful, performance-based feedback. The objective of this proposal is to compare the effectiveness of a risk-adjusted, time-to- event CUSUM for the early detection of hospitals with outlier performance in terms of 30-day morbidity and mortality relative to the standard of episodic observed-to-expected (O-E) methodology used by the VA Surgical Quality Improvement Program (VASQIP) and the American College of Surgeons National Surgical Quality Improvement Program. Using national VASQIP data, we intend to: 1.) evaluate whether the CUSUM identifies similar outlier hospitals relative to the O-E approach and to compare differences in timing for outlier identification; 2.) estimate the number of at risk surgical procedures and post-operative patient days using CUSUM compared to O-E hospital performance evaluation. The data from this proposal will inform a future prospective evaluation of the CUSUM within the VA's existing surgical QI framework and infrastructure with the ultimate goal being eventual integration of CUSUM into VASQIP reporting. Providing hospitals with more timely data would benefit local QI efforts and could shift the paradigm away from a reactive response to episodic data to a proactive approach based on a more real-time evaluation of performance. Identifying opportunities to correct errant care processes when performance is declining rather than when it has already reached an unacceptable level could decrease the number of surgical patients at risk for unintended outcomes, decrease the costs associated with correcting errant care processes and treating potentially preventable morbidity, and make surgical care safer.