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，556，000名15岁以下的儿童接受了这种手术，需要全身麻醉。 最近的一项研究评估了6000多名医生建议进行手术的儿童的手术适应症，发现近四分之一的鼓膜造口管放置可能在临床上不合适。虽然有许多指南可以促进临床决策，但医生经常抵制使用它们，因为他们担心它们不能充分考虑个体患者的差异。 没有适当的研究已经检查了执业医生所做的决定偏离循证指南的程度，医生可能会解释任何这种差异的原因，以及这些原因在多大程度上证明偏离指南。我们建议制定和验证质量措施，以评估儿童鼓膜造孔管使用的适当性。我们将在一个具有全国代表性的专家医师小组的协助下制定基于证据的适当性指南，该专家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获得质量措施，并将其回顾性地应用于接受该程序的大量经济，种族和民族多样化的儿童人群。 在5家纽约大都会区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个鼓膜造孔管放置的适当性。 对于一个样本的情况下，我们将采访外科医生和初级保健医生，以确定因素不包括在指南中，医生认为有理由这样做的程序。 我们还将采访父母，以了解他们在决定进行手术中的作用。我们将通过重新召集专家医生小组并要求他们对偏离指南的原因的适当性进行评级，来验证治疗医生提供的理由。 我们会修订指引，把小组决定的额外因素纳入其中，作为适当的减罪情况，以制订更有效的优质措施。 最后，我们将研究适当性与各种患者，父母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.