Importance. Surgical complications represent a considerable proportion of hospital expenses. Therefore, interventions that improve surgical outcomes could reduce healthcare costs. Objective. Evaluate the effects of implementing surgical outcome monitoring using control charts to reduce hospital bed-days within 30 days following surgery, and hospital costs reimbursed for this care by the insurer. Design. National, parallel, cluster-randomised SHEWHART trial using a difference-in-difference approach. Setting. 40 surgical departments from distinct hospitals across France. Participants. 155 362 patients over the age of 18 years, who underwent hernia repair, cholecystectomy, appendectomy, bariatric, colorectal, hepatopancreatic or oesophageal and gastric surgery were included in analyses. Intervention. After the baseline assessment period (2014-2015), hospitals were randomly allocated to the intervention or control groups. In 2017-2018, the 20 hospitals assigned to the intervention were provided quarterly with control charts for monitoring their surgical outcomes (inpatient death, intensive care stay, reoperation and severe complications). At each site, pairs, consisting of one surgeon and a collaborator (surgeon, anaesthesiologist or nurse), were trained to conduct control chart team meetings, display posters in operating rooms, maintain logbooks and design improvement plans. Main outcomes. Number of hospital bed-days per patient within 30 days following surgery, including the index stay and any acute care readmissions related to the occurrence of major adverse events, and hospital costs reimbursed for this care per patient by the insurer. Results. Postintervention, hospital bed-days per patient within 30 days following surgery decreased at an adjusted ratio of rate ratio (RRR) of 0.97 (95% CI 0.95 to 0.98 ; p<0.001), corresponding to a 3.3% reduction (95% CI 2.1% to 4.6%) for intervention hospitals versus control hospitals. Hospital costs reimbursed for this care per patient by the insurer significantly decreased at an adjusted ratio of cost ratio (RCR) of 0.99 (95% CI 0.98 to 1.00 ; p=0.01), corresponding to a 1.3% decrease (95% CI 0.0% to 2.6%). The consumption of a total of 8910 hospital bed-days (95% CI 5611 to 12 634 bed-days) and euro2 615 524 (95% CI euro 32 366 to euro 5 405 528) was avoided in the intervention hospitals postintervention. Conclusions. Using control charts paired with indicator feedback to surgical teams was associated with significant reductions in hospital bed-days within 30 days following surgery, and hospital costs reimbursed for this care by the insurer.
Commentaire du Dr Marius Laurent (PAQS)
- Les auteurs avaient déjà démontré que des actions d’amélioration dont les résultats illustrés auprès d’équipes chirurgicales par la mise à disposition de « control charts » (cartes de contrôle) et commentés régulièrement étaient de nature à réduire des complications chirurgicales, les réinterventions et le recours aux soins intensifs [1]. Ils concluent l’étude en présentant des chiffres de réduction des coûts d’hospitalisation que la société doit prendre en charge. Ils mettent en garde contre la vision simplificatrice qui voudrait que l’unique monitorage par des cartes de contrôle dites de Shewhart soit la base du changement : il est évident que ce feed-back illustre des tentatives d’amélioration, mais que ce sont ces dernières, et l’enthousiasme des équipes qui sont le moteur du progrès. Toutefois, l’expérience acquise par ailleurs lors de la mise en place des « care bundles » (bouquets de soins) montre que cette rétroaction du suivi d’indicateurs vers les équipes, présenté sous forme graphique, a un impact important, surtout si elle est aussi immédiate que possible. Les efforts pour rendre plus lisible et didactique l’interprétation du suivi d’indicateurs (de résultats dans le cas présent, de moyens aussi dans le cas des bouquets de soins) sont facilement automatisés, mobilisent peu de ressources et valent la peine d’être vantés et utilisés.
Skier S, Pascal L, Polazzi S, et al.Economic analysis of surgical outcome monitoring using control charts : The shewhart cluster randomised trial. BMJ Qual Saf 2023.
Doi : 10.1136/bmjqs-2022-015390.
Note :
1- Duclos A, Chollet F, Pascal L, et al. Effect of monitoring surgical outcomes using control charts to reduce major adverse events in patients: Cluster randomised trial. Br Med J 2020;371:m3840.