The Quality Metric Prolonged Length of Stay Misses Clinically Important Adverse Events

摘要

DiscussionReferencesThe National Quality Forum endorses prolonged length of stay of more than 14 days (PLOS) as a quality metric for lobectomy for lung cancer. Because PLOS rates are lower than complication rates, we hypothesized that PLOS misses a significant proportion of clinically important events.MethodsA retrospective study was performed on patients undergoing lobectomy (2000 to 2009). The severity of adverse events was based on the National Cancer Institute common terminology criteria for adverse events (grade 2 or higher indicates symptoms or need for medical intervention; grade 5 indicates death).ResultsAmong 2,667 patients, 163 (6%) experienced PLOS and 773 (29%) experienced an adverse event. Although the frequency of adverse events was higher among the PLOS group (99% [161 of 163] versus 24% [612 of 2504]), 79% (612 of 773) of adverse events occurred in the non-PLOS group. Whereas PLOS was associated with more severe events, 89% of those in the non-PLOS group experienced a grade 2 or higher event. Likewise, although PLOS was associated with the lowest 5-year survival rate (31%), patients in the non-PLOS group who had an adverse event had significantly lower survival rates than patients in the non-PLOS group who did not have any adverse events (55% versus 68%, p < 0.001; adjusted hazard ratio 1.3 [95% confidence interval: 1.1 to 1.6]).ConclusionsThe PLOS missed a high proportion of adverse events defined by the need for ongoing inpatient therapy and an association with poor long-term survival. These findings have implications for efficient and fair performance assessment in the setting of a quality improvement program.CTSNet classification:4, 10Since 1990, the Thoracic Surgery Directors Association (TSDA) has presented an award annually to an outstanding paper presented by a resident at The Society of Thoracic Surgeons (STS) Annual Meeting. Established to encourage resident research in cardiothoracic surgery, the award was renamed in 2009 to honor Benson R. Wilcox, MD, who was instrumental in establishing TSDA and who served as the organization's first secretary/treasurer and later as its president.Abstracts submitted to the STS Program Committee representing research performed by residents were forwarded to the TSDA to be considered for this award. The abstracts were reviewed, and the winner selected by the TSDA Executive Committee.In 2012, the recipient of the TSDA Benson R. Wilcox Award was Farhood Farjah, MD, a resident at Memorial Sloan-Kettering Cancer Center.Outcomes measurement is a popular approach to quality improvement in the field of surgery. Operative mortality is the most commonly used metric to evaluate potential gaps in quality and solutions for improvement. For most procedures, however, early deaths occur too infrequently and overall caseloads are too low to allow for statistically robust performance discrimination among surgeons or institutions [