Structure, Process and Outcomes in Cancer Surgery

描述（由申请人提供）：每年有数千名美国人在接受择期癌症手术时死亡或出现严重并发症。医院和外科医生死亡率的广泛变化表明，癌症手术的安全性可以大大提高，但质量改进工作目前受到缺乏了解的基础上的变化在医院的性能机制的限制。例如，这些医院的高死亡率是否可归因于手术或医疗并发症？高死亡率的医院只是有更高的并发症发生率，还是他们在并发症发生后不太精通管理？这些问题的答案对可能影响癌症手术质量有意义的改善的干预类型有明显的影响。过多死亡率主要归因于手术部位并发症的证据意味着需要采取旨在确保外科医生熟练程度的干预措施。具体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。在此背景下，我们的项目有两个具体目标：1。确定癌症手术死亡率高的医院手术死亡率过高的原因。利用2005- 2006年国家癌症数据库的数据，我们将确定美国癌症手术死亡率最低的20家医院（约1.5%）和死亡率最高的30家医院（约10%）。基于临床图表审查，我们将首先比较这两组医院的死因特异性死亡率。然后，我们将研究病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.确定导致并发症发生率和死亡率差异的护理资源和过程。随着对高死亡率医院中过多死亡的临床原因有了更好的了解，我们将研究两个医院组之间结果差异的具体结构变量和护理过程。这些因素包括可能降低并发症发生率的因素（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。项目叙述：虽然癌症手术的并发症和死亡率在医院之间差异很大，但由于缺乏对某些医院的结果优于其他医院的确切理解，旨在提高手术质量的努力受到阻碍。在这项对50家医院的全国性研究中，我们将首先确定高死亡率医院手术死亡率过高的临床原因。然后，我们将确定的资源和护理过程，占医院的结果的差异，确定最佳实践和改善护理在所有设置的最终目标。

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.