Structure, Process and Outcomes in Cancer Surgery

描述（由申请人提供）：每年有成千上万的美国人在选择性癌症手术中死亡或经历严重并发症。医院和外科医生之间死亡率的巨大差异表明，癌症手术的安全性可以大大提高，但由于缺乏对医院表现差异的潜在机制的了解，目前质量提高的努力受到限制。例如，这些医院的高死亡率是否可归因于手术或内科并发症？是高死亡率医院的并发症发生率更高，还是他们在发生并发症后对并发症的处理能力较差？这些问题的答案对于癌症手术中可能产生有意义的质量改善的干预类型具有明显的含义。有证据表明，过高的死亡率主要归因于手术部位并发症，这意味着需要采取旨在确保外科医生熟练程度的干预措施。特定医疗并发症的变化反而表明需要关注与围手术期护理相关的过程。在这种情况下，我们的项目有两个具体目标：1。目的：确定癌症手术死亡率高的医院中手术死亡过多的原因。使用2005- 2006年国家癌症数据库的数据，我们将确定20家美国癌症手术死亡率最低的医院（约1.5%）和30家死亡率最高的医院（约10%）。根据临床图表回顾，我们将首先比较这两组医院的病因特异性死亡率。然后，我们将研究死因特异性死亡率的差异是否可归因于并发症发生率或抢救失败率的差异。2. 确定造成并发症发生率和死亡率差异的资源和护理程序。在更好地了解高死亡率医院超额死亡的临床原因后，我们将检查导致两组医院之间结果差异的具体结构变量和护理过程。这些因素可能会减少并发症的发生(例如…（在围手术期护理中坚持循证实践）或提高并发症患者的抢救率。项目简介：尽管不同医院的癌症手术并发症和死亡率差异很大，但由于缺乏对某些医院比其他医院疗效更好的确切原因的理解，旨在提高手术质量的努力受到了阻碍。在这项涉及50家医院的全国性研究中，我们将首先确定高死亡率医院中手术死亡过多的临床原因。然后，我们将确定导致医院结果差异的护理资源和流程，最终目标是确定最佳实践并改善所有环境中的护理。

DESCRIPTION (provided by applicant): Every year thousands of Americans die or experience serious complications undergoing elective cancer surgery. Wide variations in mortality rates across both hospitals and surgeons suggest that the safety of cancer surgery could be improved substantially, but quality improvement efforts are currently limited by a lack of understanding about mechanisms underlying variations in hospital performance. For example, are high mortality rates at these hospitals attributable to surgical or medical complications? Do high mortality hospitals simply have higher complication rates, or are they instead less proficient at managing complications once they have occurred? Answers to such questions have obvious implications for the types of interventions likely to effect meaningful quality improvement in cancer surgery. Evidence that excess mortality is attributable primarily to surgical site complications would imply the need for interventions aimed at ensuring surgeon proficiency. Variation in specific medical complications would instead suggest the need to focus on processes related to perioperative care. In this context, our project has two specific aims: 1. To determine the causes of excess operative deaths at hospitals with high cancer surgery mortality. Using data from the 2005-6 National Cancer Database, we will identify 20 hospitals with among the lowest cancer surgery mortality rates in the United States (approximately 1.5%) and 30 hospitals with the highest mortality rates (approximately 10%). Based on clinical chart review, we will first compare these two groups of hospitals with regard to cause-specific mortality rates. We will then examine whether differences in cause- specific mortality rates are attributable to differences in the incidence of complications or failure to rescue rates. 2. To identify resources and processes of care that account for differences in complication rates and mortality. With a better understanding of the clinical causes of excess deaths at high mortality hospitals, we will then examine specific structural variables and processes of care that underlie differences in outcomes between the 2 hospital groups. These include factors that may reduce the incidence of complications (e.g.., adherence to evidence-based practices in perioperative care) or improve rescue rates in patients with complications.Project Narrative: Although complication and mortality rates with cancer surgery vary widely across hospitals, efforts aimed improving surgical quality are hindered by a lack of understanding about exactly why some hospitals have better outcomes than others. In this national study of 50 hospitals, we will first determine the clinical causes of excess operative deaths at hospitals with high mortality. We will then identify the resources and processes of care that account for differences in hospital outcomes, with the ultimate goal of identifying best practices and improving care in all settings.