Comparative Effectiveness of Alternative Strategies for Monitoring Hospital Surgical Performance

摘要 与目前监测外科护理质量的方法相关的重要限制包括： (A)回顾和插曲(例如：每季度、每两年等)创建时间的反馈方法 在业绩下降和医院被告知之间存在滞后；(B)临床上的 使用当前的情节分析结构，有意义的糟糕表现可能无法被发现；(C)大多数 医疗保健实体愿意接受平均绩效，但如果绩效开始下降，则会做出回应 低于可接受的门槛。因此，可以缩短反馈时间滞后的替代方法， 改进对围术期护理流程可能不佳的医院的检测，或激励 医院在计划改进方面更加积极主动可以促进当前的质量改进 并为VHA带来实实在在的好处。这项提案的总体目标是产生比较 关于监测退伍军人医院手术绩效的新的替代方法的有效性数据 目前的标准是对情节数据进行分析和反馈。具体目标是：(1)比较累积和 (一种从行业借鉴的统计过程控制方法)到阶段性观察到预期 退伍军人医院手术效果的评估方法；(2)评估30天的综合结果 死亡率、主要发病率和再手术作为机构绩效下降的指标 仅30天死亡率或总发病率。这项工作将涉及医院层面的观察性设计，使用 住院患者的VA外科质量改进计划(VASQIP)数据， 2010至2016年间，血管、胸部、泌尿生殖、整形外科、脊柱或神经外科手术。数据 将用于对这些监控VA的替代QI策略进行比较有效性分析 与目前30天死亡或死亡事件报告的标准相比，医院的手术表现 个别发病率。这个项目是新颖的，因为它将是工业质量控制的首次应用 VASQIP技术，将提供有关替代方法的重要真实世界比较数据 评估医院绩效，并将在现有VASQIP的背景下评估这些方法 框架和基础设施，以促进未来的预期评价和最终实施。它是 预期的分析将证明这些替代方法可能具有重大价值 医院的地方质量改进努力。纳入其他监测外科手术的方法 VASQIP的结果可能会对VHA和退伍军人产生显著的好处，因为他们更早认识到 具有潜在问题的围术期护理流程与次优后护理相关的医院 手术结果，降低纠正错误护理过程的成本，通过以下方式降低发病率 更早地发现和解决这些错误的过程，以及公众认为退伍军人管理局仍然 手术质量在全国处于领先地位。鉴于VHA目前的重点是确保各级和#年的优质护理 在所有护理环境中，这种替代方法也可能影响现有的质量改进 手术以外的计划或新举措也是如此。

Abstract Important limitations associated with current approaches for monitoring the quality of surgical care include: (a) the retrospective and episodic (e.g.: quarterly, bi-annually, etc.) approach to feedback which creates a time lag between when performance is declining and when the hospital is made aware; (b) small clusters of clinically meaningful poor performance may go of undetected using current episodic analytic structures; (c) most healthcare entities are willing to accept average performance, but will respond if performance starts to fall below an acceptable threshold. As such, alternative approaches that could shorten the time lag for feedback, improve the detection of hospitals with potentially suboptimal perioperative care processes, or inspire hospitals to be more proactive in programmatic improvement could enhance current quality improvement efforts and have tangible benefits for VHA. The overall goal of this proposal is to generate comparative effectiveness data on novel, alternative approaches for monitoring VA hospital surgical performance relative to the current standard of episodic data analysis and feedback. The specific aims are to: (1) compare the CUSUM (a statistical process control methodology borrowed from industry) to the episodic Observed-to-Expected approach for evaluating surgical performance at VA hospitals; (2) evaluate a composite outcome of 30-day mortality, major morbidity, and reoperation as an indicator of declining institutional performance relative to 30-day mortality or overall morbidity alone. This work will involve a hospital-level, observational design using VA Surgical Quality Improvement Program (VASQIP) data for patients who underwent inpatient general, vascular, thoracic, genitourinary, orthopedic, spine, or neurosurgical operations between 2010 and 2016. Data will be used to conduct a comparative effectiveness analysis of these alternative QI strategies for monitoring VA hospital surgical performance relative to the current standard of episodic reporting of 30-day mortality or morbidity individually. This project is novel because it will be the first application of industrial quality control techniques to VASQIP, will provide important real-world comparative data on alternative approaches for evaluating hospital performance, and will evaluate such approaches within the context of the existing VASQIP framework and infrastructure to facilitate future prospective evaluation and eventual implementation. It is anticipated the analyses will demonstrate these alternative approaches could have significant value for hospitals' local quality improvement efforts. Incorporating additional approaches for monitoring surgical outcomes into VASQIP could have notable benefits for VHA and Veterans through earlier recognition of hospitals with potentially problematic perioperative care processes that are associated with suboptimal post- operative outcomes, decreased costs for correcting errant care processes, decreased rates of morbidity through the earlier identification and resolution of such errant processes, and the public perception that the VA remains a national leader in surgical quality. Given the VHA's current focus on ensuring quality care at all levels and in all care settings, it is feasible such alternative approaches could also influence existing quality improvement programs or new initiatives outside of surgery as well.