MEASURING AND IMPROVING QUALITY: CAROTID ENDARTERECTOMY

颈动脉内膜切除术是一种外科手术， 老年人预防中风 它的年发病率正在迅速上升， 在1991年到1994年间，全国增长了61%。过去的研究 提出了与此程序有关的重大质量问题， 包括：选择不合适的手术候选人，高 基于社区的研究中的并发症发生率， 供应商数量和并发症之间的关系， 使用率的种族差异。 最近的研究产生了许多新的 关于这一行动的有效性的数据，但很少有新的数据， 在乎 我们建议调查护理质量在颈动脉内膜切除术， 一项回顾性、多队列、2期研究， 适当性、风险调整后的并发症（死亡、中风和 心肌梗死），以及特定的外科手术 护理过程到结果。 在第一阶段，我们将研究 在7家合作医院接受治疗。 在第二阶段，我们将 进行两项平行调查。 我们将研究一个大的，分层的 从纽约州随机抽取了大约8000个医疗保险病例， 足够大的样本来建立风险调整后的稳健模型 围手术期并发症 我们会检查合适性，风险- 调整的结果和手术护理过程。试图 描述最佳手术实践，我们将评估 特定的外科护理过程与低的 风险调整的围手术期并发症。 此外，我们还将探讨 医院和外科医生数量与风险调整关系 围手术期并发症 我们还将评估 种族和得体之间的区别 在第二阶段的第二部分，我们将设计、实施和评估一个 在7个合作项目中进行了一系列质量改进干预 医院的 外科医生的积极参与， 在这些机构的颈动脉内膜切除术，我们将检查阶段 1数据的适当性。 我们将研究 合作医院在外科手术护理过程中显示， 2与风险调整后的围手术期结局改善相关。 我们将在每家医院确定存在改进机会的地方 患者选择的适当性和 手术过程的护理、干预改善、影响评估 这些干预措施。

Carotid endarterectomy is a surgical procedure commonly performed among the elderly to prevent stroke. Its annual incidence is rising rapidly, up 61 percent nationally between 1991 and 1994. Past research has suggested significant quality problems relating to this procedure, including: the selection of inappropriate surgical candidates, high rates of complications in community-based studies, an inverse relationship between provider volume and complications, and substantial racial disparities in use rates. Recent studies have produced much new data on the efficacy of this operation but few new data on quality of care. We propose to investigate quality of care in carotid endarterectomy in a retrospective, multiple cohort, 2-phase study, measuring appropriateness, risk-adjusted complications (death, stroke, and myocardial infarction), and the relationship of specific surgical processes of care to outcomes. In the phase 1, we will study patients treated in a group of 7 collaborating hospitals. In phase 2, we will conduct 2 parallel investigations. We will study a large, stratified random sample of about 8000 Medicare cases from across New York State, a sample large enough to build robust models of risk-adjusted perioperative complications. We will examine appropriateness, risk- adjusted outcomes, and surgical processes of care. Attempting to characterize best surgical practices, we will assess the extent to which specific surgical processes of care are associated with low rates of risk-adjusted perioperative complications. In addition, we will explore the relationship of hospital and surgeon volume to risk-adjusted perioperative complications. We will also assess the relationship between race and appropriateness. In the second part of phase 2, we will design, conduct, and evaluate a series of quality improvement interventions at the 7 collaborating hospitals. With the active participation of the surgeons who perform carotid endarterectomy at these institutions, we will examine the phase 1 data on appropriateness. We will examine differences among collaborating hospitals in the surgical processes of care shown in Phase 2 to be associated with improved risk-adjusted perioperative outcomes. We will determine at each hospital where opportunities exist to improve both the appropriateness of patient selection and the effectiveness of surgical processes of care, intervene to improve, and assess the impact of those interventions.