DEVELOPING AND VALIDATING QUALITY MEASURES FOR CHILDREN

鼓室造瘘管置入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需要全身麻醉的手术。最近的一项研究评估了6000多名被医生推荐进行鼓室造口手术的儿童的手术适应症，发现几乎四分之一的建议鼓室造瘘管放置可能在临床上是不合适的。虽然存在许多指南来促进临床决策，但医生经常拒绝使用它们，因为他们担心它们没有充分考虑到患者的个体差异。没有一项关于适当性的研究考察了执业医生做出的决定在多大程度上偏离了循证指南，医生可能给出的解释任何此类差异的原因，以及这些原因在多大程度上证明了偏离指南的合理性。我们建议开发和验证质量测量方法来评估儿童鼓室造瘘管的使用是否合适。我们将在一个具有全国代表性的专家医师小组的协助下，创建基于证据的适当性指南，该小组将由儿科和外科专业学会合作组成。我们将从这些指导方针中得出质量标准，并将其追溯应用于接受手术的大量不同经济、种族和民族的儿童人口。在纽约5家大都会医院儿科医生和耳鼻喉科医生的共同支持下，我们将评估大约1250个鼓室造瘘管放置的适宜性。对于一个病例样本，我们将采访外科医生和初级保健医生，以确定医生认为有理由进行该程序的指南中未包括的因素。我们还将采访父母，以了解他们在决定进行手术时所扮演的角色。我们将重新召集专家内科医生小组，并要求他们评估所给出的偏离指南的理由是否适当，从而验证治疗医生提供的理由是否合理。我们将修订指南，纳入专家小组确定为适当的可减轻处罚的其他因素，以制定具有更高有效性的质量措施。最后，我们将研究适当性与患者、父母和医生的各种属性之间的关系。

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.