急性心肌梗死治疗的地域差异：合作心血管项目

Geographic variation in the treatment of acute myocardial infarction: the Cooperative Cardiovascular Project.

作者信息

O'Connor G T, Quinton H B, Traven N D, Ramunno L D, Dodds T A, Marciniak T A, Wennberg J E

机构信息

Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, NH 03755, USA. gerald.t.o'

出版信息

JAMA. 1999 Feb 17;281(7):627-33. doi: 10.1001/jama.281.7.627.

DOI:10.1001/jama.281.7.627

PMID:10029124

Abstract

CONTEXT

Quality indicators for the treatment of acute myocardial infarction include pharmacologic therapy, reperfusion, and smoking cessation advice, but these therapies may not be administered to all patients who could benefit from them.

OBJECTIVE

To assess geographic variation in adherence to quality indicators for treatment of acute myocardial infarction.

DESIGN

Inception cohort using data from the Health Care Financing Administration Cooperative Cardiovascular Project.

SETTING

Acute care hospitals in the United States.

PATIENTS

A total of 186800 Medicare beneficiaries hospitalized for treatment of confirmed acute myocardial infarction from February 1994 through July 1995.

MAIN OUTCOME MEASURES

Adherence to quality indicators for pharmacologic therapy, reperfusion, and smoking cessation advice for patients judged to be ideal candidates for these therapies. The mean rates of adherence to these quality indicators for the entire United States were determined, and the 20th and 80th percentiles of the age- and sex-adjusted rates for each of 306 hospital referral regions were contrasted (mean rate [20th-80th percentiles]).

RESULTS

Aspirin was used frequently both during hospitalization (86.2% [82.6%-90.1%]) and at discharge (77.8% [72.5% -83.9%]). Calcium channel blockers were withheld from most patients with impaired left ventricular function (81.9% [73.6%-90.8%]). Lower rates were seen in the use of angiotensin-converting enzyme inhibitors at discharge (59.3% [49.2%-69.2%]); reperfusion, using thrombolytic therapy or coronary angioplasty (67.2% [59.8%-75.1%]); prescription of beta-blockers at discharge (49.5% [35.8%-61.5%]); and for smoking cessation advice (41.9% [32.8%-51.3%]).

CONCLUSIONS

Substantial geographic variation exists in the treatment of patients with acute myocardial infarction, and these gaps between knowledge and practice have important consequences. Therapies with proven benefit for AMI are underused despite strong evidence that their use will result in better patient outcomes.

摘要

背景

急性心肌梗死治疗的质量指标包括药物治疗、再灌注治疗和戒烟建议，但这些治疗方法可能并未应用于所有能从中受益的患者。

目的

评估急性心肌梗死治疗质量指标的依从性在地域上的差异。

设计

采用医疗保健财务管理局合作心血管项目的数据进行起始队列研究。

地点

美国的急症医院。

患者

1994年2月至1995年7月期间因确诊急性心肌梗死住院治疗的186800名医疗保险受益人。

主要观察指标

对于被判定为这些治疗理想候选者的患者，药物治疗、再灌注治疗和戒烟建议的质量指标依从性。确定了美国全国这些质量指标的平均依从率，并对比了306个医院转诊地区中每个地区按年龄和性别调整后的依从率的第20百分位数和第80百分位数（平均率[第20 - 80百分位数]）。

结果

阿司匹林在住院期间（86.2%[82.6% - 90.1%]）和出院时（77.8%[72.5% - 83.9%]）的使用频率都很高。大多数左心室功能受损的患者未使用钙通道阻滞剂（81.9%[73.6% - 90.8%]）。出院时血管紧张素转换酶抑制剂的使用率较低（59.3%[49.2% - 69.2%]）；再灌注治疗，采用溶栓疗法或冠状动脉成形术（67.2%[59.8% - 75.1%]）；出院时β受体阻滞剂的处方率（49.5%[35.8% - 61.5%]）；以及戒烟建议（41.9%[32.8% - 51.3%]）。