Optimizing the Risk-Adjusted CUSUM for Monitoring Hospital Non-cardiac Perioperative Outcomes

国家手术质量改进（QI）计划，如退伍军人事务部（VA）手术质量 改进计划（VASQIP）和美国外科医师学会国家外科质量 改善计划（ACS NSQIP），收集、分析并向医院提供机构级的、风险调整后的 关于间歇性的围手术期发病和死亡的数据（例如，季度）时尚。医院反过来使用 这些数据，以告知他们的本地QI工作。虽然这种情景式的反馈方式几乎是所有 国家外科QI计划，它与两个重要的限制有关：1）当 医院绩效正在下降，当在季度数据结束时提供通知时， 确定期; 2）检测可能发生的潜在有意义的不良事件集群的能力有限 不被情景评价策略所认可。一种潜在的替代分析策略， 补充和增强当前手术QI的方法是累积和（CUSUM）。该博物馆是 一种统计过程控制方法，已在工业环境中使用，以提供实时 监控生产过程的质量。在卫生保健领域， 当结果变化接近不可接受的水平并且非常适合于检测相对小的时， 然而，随着时间的推移，在给定的结果中持续变化。它目前由联合器官移植网络使用， 分享会员资格和专业标准委员会，一个在移植手术的监管机构， 美国，用于实时监测医院级移植后患者和移植物长期存活率。在 此外，我们小组正在进行的工作表明，该组织一贯提供早期的，有意义的， 关于围手术期结局的基于绩效的机构反馈。本提案的总体目标是 是在我们先前工作的基础上，探索如何优化在国家外科QI中使用的CAPSUUM 这些计划能够及早和准确地发现业绩不佳的医院。使用国家VASQIP 数据，我们的目标是：1）评估给定季度的多个CQUM信号是否减少错误 积极的医院检测; 2）探索是否连续运行的CIMUM（多个季度） 减少假阳性医院检测; 3）描述与假阳性和假阳性相关的医院因素 消极的信号。这项工作将有助于为今后对该研究所进行的前瞻性评价提供信息， 最终在VASQIP中实现。利用VASQIP现有的基础设施， 有了更多的实时、可操作的数据，最终可能会发现以前不被重视的问题， 不理想的护理过程，使患者免于可预防的发病和/或死亡。

National surgical quality improvement (QI) programs, such as the Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP) and the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), collect, analyze, and provide hospitals with institution-level, risk-adjusted data on perioperative morbidity and mortality in an episodic (e.g., quarterly) fashion. Hospitals in turn use these data to inform their local QI efforts. While this episodic approach to feedback is a convention in nearly all national surgical QI programs, it is associated with two important limitations: 1) a time lag between when hospital performance is declining and when notification is provided at the end of the quarterly data ascertainment period; 2) a limited ability to detect potentially meaningful clusters of adverse events that may go unrecognized with episodic evaluation strategies. One potential alternative analytic strategy that could supplement and enhance current approaches to surgical QI is the cumulative sum (CUSUM). The CUSUM is a statistical process control method that has been utilized in the industrial setting to provide real-time monitoring of the quality of production processes. In health care, the CUSUM has been used to ascertain when outcome variation is approaching an unacceptable level and is well-suited for detecting relatively small, yet persistent, changes in a given outcome over time. It is currently used by the United Network for Organ Sharing Membership and Profession Standard Committee, a regulatory body for transplant surgery in the United States, for monitoring hospital-level post-transplant patient and graft long-term survival in real-time. In addition, our group’s ongoing work has shown the CUSUM consistently provides early, meaningful, performance-based institutional feedback regarding perioperative outcomes. The overall goal of this proposal is to build upon our prior work by exploring how to optimize the CUSUM for use within national surgical QI programs to enable early and accurate detection of hospitals with poor performance. Using national VASQIP data, our goals are to: 1) evaluate whether multiple CUSUM signals in a given quarter decreases false positive hospital detection; 2) explore whether a continuously running CUSUM (over multiple quarters) decreases false positive hospital detection; 3) describe hospital factors associated with false positive and false negative CUSUM signaling. This work will help to inform a future prospective evaluation of the CUSUM and eventual implementation withing VASQIP. Leveraging VASQIP’s existing infrastructure to provide institutions with more real-time, actionable data could ultimately result in the detection of previously unappreciated suboptimal care processes and save patients from preventable morbidity and/or mortality.