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

项目概要/摘要 当代外科质量改进（QI）计划为医院提供了情景反馈。主要有两 与此方法相关的限制。第一个是数据抽象、分析和后续处理所需的时间。 反馈在医院绩效下降和医院 接收这些信息。第二个是目前的情景分析方法无法明确说明 时间作为变量的影响（即：在短时间内发生一系列事件）。情景数据输入 医院的当地QI团队处于不利地位，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，在性能下降和性能下降之间的时间间隔内接受治疗的患者 被理解为有暴露于次优围手术期护理过程的潜在风险。的累积和 （CSAUM）是传统上用于监控生产质量的工业统计过程控制方法 过程，并确保过程高效、有效地运行，并充分发挥潜力。这座博物馆非常适合 用于确定罕见结果随时间的变化，对多重统计检验有弹性，并明确说明 时间作为变量的影响。它已被用于医疗保健评估，并显示出提供早期的，有意义的， 基于绩效的反馈本提案的目的是比较风险调整后的 用于早期检测在30天发病率和死亡率方面具有离群值性能的医院的事件CAMEUM 相对于VA手术质量部使用的发作性符合预期（O-E）方法的标准 美国外科医师学会国家外科质量改进计划（VASQIP） 程序.使用国家VASQIP数据，我们打算：1。评估CNOUM是否识别出类似离群值 医院相对于O-E方法，并比较离群值识别时间的差异; 2.）估计 与O-E医院相比，使用CIMUM的风险外科手术和术后患者天数 业绩评价该提案中的数据将为未来的CIMUM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CIMUM 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 从对偶发数据的被动反应转变为基于更实时评估的主动方法， 性能在绩效下降而不是绩效下降时，确定纠正错误护理流程的机会 已经达到不可接受的水平，可能会减少处于意外结果风险中的手术患者数量， 降低与纠正错误的护理过程和治疗潜在可预防的疾病相关的成本， 让手术更安全

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.