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首页> 外文期刊>The Milbank quarterly >Ranking Hospitals Based on Preventable Hospital Death Rates: A Systematic Review With Implications for Both Direct Measurement and Indirect Measurement Through Standardized Mortality Rates
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Ranking Hospitals Based on Preventable Hospital Death Rates: A Systematic Review With Implications for Both Direct Measurement and Indirect Measurement Through Standardized Mortality Rates

机译：基于预防医院死亡率的排名医院：通过标准化死亡率对直接测量和间接测量的影响进行系统审查

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Policy Points The use of standardized mortality rates (SMRs) to profile hospitals presumes differences in preventable deaths, and at least one health system has suggested measuring preventable death rates of hospitals for comparison across time or in league tables. The influence of reliability on the optimal review number per case note or hospital for such a program has not been explored. Estimates for preventable death rates using implicit case note reviews by clinicians are quite low, suggesting that SMRs will not work well to rank hospitals, and any misspecification of the risk‐adjustment models will produce a high risk of mislabelling outliers. Most studies achieve only fair to moderate reliability of the direct assessment of whether a death is preventable, and thus it is likely that substantial numbers of reviews of deaths would be required to distinguish preventable from nonpreventable deaths as part of learning from individual cases, or for profiling hospitals. Furthermore, population‐ and hospital system–specific data on the variation in preventable deaths or adverse events across the hospitals and providers to be compared are required in order to design a measurement procedure and the number of reviews needed to distinguish between the patients or hospitals. Context There is interest in monitoring avoidable or preventable deaths measured directly or indirectly through standardized mortality rates (SMRs). While there have been numerous studies in recent years on adverse events, including preventable deaths, using implicit case note reviews by clinicians, no systematic reviews have aimed to summarize the estimates or the variations in methodologies used to derive these estimates. We reviewed studies that use implicit case note reviews to estimate the range of preventable death rates observed, the measurement characteristics of those estimates, and the measurement procedures used to generate them. We comment on the implications for monitoring SMRs and illustrate a way to calculate the number of reviews needed to establish a reliable estimate of the preventability of one death or the hospital preventable death rate. Methods We conducted a systematic review of the literature supplemented by a reanalysis of authors’ previously published and unpublished data and measurement design calculations. We conducted initial searches in PubMed, MEDLINE (OvidSP), and ISI Web of Knowledge in June 2010 and updated them in June 2012 and December 2017. Eligibility criteria included studies of hospital‐wide admissions from general and acute medical wards where preventable death rates are provided or can be estimated and that can provide interobserver variations. Findings Twenty‐three studies were included from 1985 to 2017. Recent larger studies suggest consistently low rates of preventable deaths (interquartile range of 3.0%‐6.0% since 2008). Reliability of a single review for distinguishing between individual cases with regard to the preventability of death had a Kappa statistic of 0.10‐0.50 for deaths and 0.21‐0.76 for adverse events. A Kappa of 0.35 would require an average of 8 to 17 reviews of a single case to be precise enough to have confidence in high‐stakes decisions to change care procedures or impose sanctions within a hospital as a result. No study estimated the variation in preventable deaths across hospitals, although we were able to reanalyze one study to obtain an estimate. Based on this estimate, 200 to 300 total case note reviews per hospital could be required to reliably distinguish between hospitals. The studies displayed considerable heterogeneity: 13/23 studies defined preventable death with a threshold of greater than or equal to four in a six‐category Likert scale and 11/24 involved a two‐stage screening process with nurses at the first stage and physicians at the second. Fifteen studies provided expert clinical review support for reviewer disagreements, advice, and quality control. A “generalist
机译：政策指点使用标准化的死亡率（SMR）来介绍，外部医院假定可预防死亡的差异，并且至少有一个卫生系统建议在跨时间或联盟表中衡量医院的可预防性死亡率。尚未探讨可靠性对此类计划的最佳审查编号的影响。使用隐式案例的可预防性死亡率估计注释临床医生的评论非常低，这表明SMR不适用于排名医院，以及风险调整模型的任何误操作会产生误标注异常值的高风险。大多数研究只能公平地对直接评估死亡是可预防的，因此可能需要大量的死亡审查，以区分免于不可抗拒的死亡，作为从个人案件的学习，或分析医院。此外，有关待比较的可预防性死亡或不良事件的变异的人口和医院的特定数据是为了设计测量程序和区分患者或医院所需的评论。背景信息有兴趣通过标准化死亡率（SMR）直接或间接地监测可避免或可预防的死亡。虽然近年来近年来在不良事件上进行了许多研究，但在包括可预防的死亡的情况下，使用临床医生的隐性案例注释审查，没有系统评论旨在总结估计或用于导出这些估计的方法的变化。我们审查了使用隐式案例的研究注意审查以估算观察到的可预防性死亡率范围，这些估计的测量特征以及用于生成它们的测量程序。我们评论了监测SMR的影响，并说明了计算确定可靠估计对一个死亡或医院可预防的死亡率的可靠估计所需的评论数量的方法。方法对提交者先前发布和未发表的数据和测量设计计算的作者分析的文献进行了系统审查。我们于2010年6月在PubMed，Medline（Ovidsp）和Isi知识网上进行了初步搜索，并于2012年6月和2017年12月更新了它们。资格标准包括关于一般和急性医疗病房的医院范围内录取的研究提供或可以估计，可以提供Interobserver变化。调查结果二十三项研究包括于1985年至2017年。最近的较大研究表明，自2008年以来的预防性死亡率（四分位数范围为3.0％-6.0％）。在死亡预防性方面区分各个案件的单一审查的可靠性具有0.10-0.50的Kappa统计，但不良事件的死亡和0.21-0.76。 kappa为0.35，平均需要8至17条评论，对单一案例足够精确，以便对高赌注决策具有信心，以改变护理程序或因此在医院内施加制裁。虽然我们能够重新分析一项研究以获得估计，但估计医院防止死亡的变化估计。基于此估算，200至300案总案例请注意，每家医院的审查可能需要可靠地区分医院。这些研究显示了相当大的异质性：13/23研究可预防可预防的死亡，六分类李克特量表中的阈值大于或等于四，11/24涉及一个在第一阶段和医生的护士进行两级筛选过程第二。十五项研究为审稿人分歧，建议和质量控制提供了专家临床审查支持。一个“通用主义者

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