DEVELOPING AND VALIDATING QUALITY MEASURES FOR CHILDREN

鼓膜造口置管是儿童最常见的外科手术。1994年，55.6万名15岁以下的儿童接受了这种需要全身麻醉的手术。最近的一项研究评估了6000多名由医生推荐的儿童的手术指征，发现近四分之一的鼓膜造口管放置可能在临床上不合适。虽然存在许多指导方针以促进临床决策，但医生往往拒绝使用它们，因为他们担心它们没有充分考虑到个体患者的可变性。没有关于适当性的研究考察了执业医生的决定偏离循证指南的程度，医生可能给出的解释任何此类差异的原因，以及这些原因证明偏离指南的程度。我们建议发展和验证质量的措施，以评估适当的鼓室造瘘管的使用在儿童。我们将在全国代表性专家医师小组的协助下制定循证适当性指南，该小组将与儿科和外科专业协会合作组成。我们将从这些指南中得出质量衡量标准，并将其回顾性地应用于接受手术的大量、经济、种族和民族不同的儿童。在纽约市区5家医院的儿科医生和耳鼻喉科医生的协作支持下，我们将评估大约1250个鼓室造瘘管放置的适宜性。对于病例样本，我们将采访外科医生和初级保健医生，以确定指导方针中未包括的医生认为有理由进行手术的因素。我们还将采访家长，以了解他们在决定是否进行手术中的作用。我们将通过重新召集专家医师小组，并要求他们对偏离指南的理由的适当性进行评级，从而验证主治医生提供的理由。我们会修订指引，纳入评审委员会认为适当的可减罪情况的其他因素，以制订更有效的质素措施。最后，我们将检查适当性与各种患者、家长和医生属性之间的关系。

Tympanostomy tube placement is the most common surgical procedure performed on children. In 1994, 556,000 children under age 15 underwent this procedure, which requires general anesthesia. One recent study evaluated the indications for surgery in over 6000 children who had been recommended for the procedure by their physicians and found that almost one-quarter of proposed tympanostomy tube placements may be clinically inappropriate. While many guidelines exist to facilitate clinical decision making, physicians often resist using them because of a concern that they do not inadequately account for individual patient variability. No study of appropriateness has examined the extent to which decisions made by practicing physicians deviate from evidence-based guidelines, the reasons physicians might give to explain any such discrepancies, and the extent to which those reasons justify deviations from the guidelines. We propose to develop and validate measures of quality to assess the appropriateness of the use of tympanostomy tubes in children. We will create evidence-based appropriateness guidelines with the assistance of a nationally-representative expert physician panel, which will be constituted by collaborating with pediatric and surgical specialty societies. We will derive quality measures from those guidelines and apply them retrospectively to a large, economically, racially, and ethnically diverse population of children who underwent the procedure. With the collaborative support of pediatricians and otolaryngologists at 5 New York metropolitan area hospitals, we will assess the appropriateness of approximately 1250 tympanostomy tube placements. For a sample of cases, we will interview surgeons and primary care physicians to ascertain factors not included in the guidelines that the physicians believed justified doing the procedure. We will also interview parents to understand their role in the decision to perform surgery. We will validate the justifications offered by the treating physicians by reconvening the expert physician panel and asking them to rate the appropriateness of the reasons given for deviating from the guidelines. We will revise the guidelines to incorporate the additional factors determined by the panel to be appropriate extenuating circumstances to produce quality measures with enhanced validity. Finally, we will examine the relationship between appropriateness and various patient, parent, and physician attributes.