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

项目概要/摘要 现代手术质量改进 (QI) 计划为医院提供间歇性反馈。主要有两个 与此方法相关的局限性。首先是数据抽象、分析以及后续所需的时间 反馈在医院绩效下降和医院绩效下降之间产生了内在的时间滞后 收到此信息。第二个是当前的情景分析方法无法明确解释 时间作为变量的影响（即：短时间内发生一系列事件）。情景数据投入 医院当地的 QI 团队处于不利地位，因为他们对绩效下降的反应必须是被动的，而不是 积极主动。此外，在表现下降和这种下降之间的时间间隔内接受治疗的患者 人们认识到，他们可能面临接受次优围手术期护理流程的风险。累计总和 (CUSUM) 是一种工业统计过程控制方法，传统上用于监控生产质量 流程并确保该流程高效、有效并充分发挥潜力。 CUSUM 非常适合 用于确定罕见结果随时间的变化，能够适应多种统计测试，并明确解释 时间作为变量的影响。它已被用于医疗保健评估，并被证明可以提供早期、有意义的、 基于绩效的反馈。该提案的目的是比较风险调整后的时间的有效性 事件 CUSUM 用于及早发现 30 天发病率和死亡率表现异常的医院 相对于 VA Surgical Quality 使用的情景观察到预期 (O-E) 方法标准 改进计划 (VASQIP) 和美国外科医生学会全国手术质量改进 计划。使用国家 VASQIP 数据，我们打算：1.) 评估 CUSUM 是否识别出类似的异常值 医院相对于 O-E 方法并比较异常值识别时间的差异； 2.) 估计 与 O-E 医院相比，使用 CUSUM 进行危险手术的次数和术后患者天数 绩效评估。该提案中的数据将为未来对 CUSUM 的前瞻性评估提供信息 VA 现有的外科 QI 框架和基础设施，最终目标是最终整合 CUSUM 进入 VASQIP 报告。为医院提供更及时的数据将有利于当地的 QI 工作，并可能改变 范式从对情景数据的被动响应转向基于更实时评估的主动方法 性能。在绩效下降时而不是在绩效下降时发现纠正错误护理流程的机会 已经达到不可接受的水平可能会减少面临意外结果风险的手术患者数量， 降低与纠正错误的护理流程和治疗潜在可预防的发病率相关的成本，以及 让手术护理更加安全。

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.