Using Patient Outcomes to Inform Surgical Education

 描述（由申请人提供）：在美国，估计每年有1000万患者接受手术。尽管结果总体上有所改善，但美国每年仍有超过12万人死于手术后。更多的人将遭受不良事件。新的研究表明，结果的变化很大一部分发生在手术医生的水平。然而，最近外科护理性质的变化，对外科手术结果的审查增加，以及值班时间改革极大地改变了外科手术培训过程。关于现代新的外科医生的质量所产生的关注证实了最近急剧增加的口腔板故障率。到目前为止，没有人能够检查现代新外科医生的质量，因为他们最近才进入劳动力市场。利用2003年引入的值班时间改革作为一个里程碑，更大的一套系统的变化，我们的目标是了解环境变化的影响，新的外科医生提供的护理质量和公共卫生的影响，在外科领域的变化对新兴的外科手术的劳动力。在这一提议中， 使用定制的医疗保险索赔数据集，包括50个州的所有新外科医生，我们将使用专门为此研究开发的新颖的两步匹配过程和差异中的差异（D-in-D）方法来检查现代培训对新外科医生产品的影响。新的外科医生将被分类为现代或传统的一年，他们进入住院医师。将为现代（AY 2009-2013）、过渡和传统（AY 1999 -2003）培训时代构建外科医生对。“两步”匹配的第一步是通过他们在同一时间段在同一医院进行的手术程序将新的和有经验的外科医生配对。第二步在每个匹配的外科医生对中匹配个体患者。使用这种两步匹配方法，我们可以控制程序，技术和患者特征，使医院内新的和有经验的外科医生治疗的患者几乎相同。使用经验丰富的外科医生作为对照的D-in-D方法最大限度地减少了与医疗保健提供随时间变化相关的混淆。匹配后回归将用于控制剩余混杂因素，如研究员身份。子集分析将允许对特定临床队列进行重点检查，以提供透明有意义的结果。此外，我们将得出多个专业和特定临床队列的熟练度曲线。目标1将检查临床结果，目标2将检查经济结果。完成该项目后，我们将能够：1）告知ACGME和ABMS关于新外科医生表现的差距，以进行后续的教育改革; 2）使用为此提案开发的方法来监测任何未来的改革; 3）向CMS（和其他付款人）和外科医生提供关于重点专业发展计划（例如，外科指导或分阶段的认证或资格认证），以提高今天提供给外科患者的护理质量，并保障将来对外科患者的护理。

 DESCRIPTION (provided by applicant): An estimated 10 million patients undergo an operative procedure annually in the United States. Despite overall improvements in outcomes, over 120,000 people die following surgery each year in the US. Many more will suffer from adverse events. Nascent research suggests that a significant proportion of the variation in outcomes occurs at the level of the operative surgeons. Yet, recent changes in the nature of surgical care, increased scrutiny of surgical outcomes, and duty-hour reform have dramatically changed the surgical training process. Resultant concerns regarding the quality of the modern new surgeons are substantiated by the recent sharp increase in the oral board failure rate. To date, no one has been able to examine the quality of the modern new surgeons because they have only recently entered the workforce. Using the introduction of the duty-hour reform in 2003 as a landmark for the larger set of systematic changes, we aim to understand the effects of environmental changes on the quality of care provided by new surgeons and the public health implications of changes in the surgical field on the emerging surgical workforce. In this proposal, using a customized Medicare claims dataset including all new surgeons across 50 states, we will use a novel two-step matching process developed specifically for this study and a difference-in-difference (D-in-D) approach to examine the effects of training in the modern era on the new surgeon product. New surgeons will be classified as modern or traditional by the year in which they entered residency. Surgeon pairs will be constructed for the modern (AY 2009-2013), transitional and traditional (AY1999-2003) training eras. The first step of the "two- step" match pairs new and experienced surgeons by the surgical procedures they performed at the same hospital in the same time period. Step two matches individual patients inside each matched surgeon pair. Using this two-step matching approach, we can control for procedure, technical and patient characteristics such that the patients treated by new and experienced surgeons within hospitals will be virtually identical. The D-in-D approach using experienced surgeons as controls minimizes confounding associated with changes in the delivery of healthcare over time. Post-match regression will be used to control for residual confounders like fellowship status. Subset analysis will permit focused examination of specific clinical cohorts to provide transparently meaningful results. Moreover, we will derive time to proficiency curves across multiple specialties and within specific clinical cohorts. Aim 1 will examine clinical outcomes and Aim 2, economic outcomes. After completing the project, we will be able to 1) inform the ACGME and ABMS on gaps in new surgeon performance for subsequent education reform, 2) use the methodology developed for this proposal to monitor any future reform and 3) advise CMS (and other payors) and surgeons on strategies for focused professional development programs (e.g., surgical coaching or phased privileging or credentialing) to improve the quality of care delivered to surgical patients today and safeguard the care of surgical patients in the future.