Schmidt Michael, Lindenauer Peter K, Fitzgerald Jan L, Benjamin Evan M
Department of Biostatistics and Epidemiology, University of Massachusetts at Amherst, Amherst, MA, USA.
Arch Intern Med. 2002 Jan 14;162(1):63-9. doi: 10.1001/archinte.162.1.63.
Beta-blockers reduce morbidity and mortality when administered to high-risk patients undergoing major noncardiac surgery, yet little is known about how often they are being prescribed. Clinical practice guidelines are tools that can be used to speed the translation of research into practice and may be one method to improve the use of beta-blockers. Before implementing any guideline, it is important to forecast its potential clinical and financial impact.
We conducted a retrospective cohort study, using administrative and medical record review data, of all adult patients undergoing major noncardiac surgery at Baystate Medical Center, Springfield, Mass, during a 1-month period in 1999. Patients with 2 or more cardiac risk factors or with documented coronary artery disease were classified as high risk and were considered eligible for treatment with a beta-blocker if they had no obvious contraindications to its use. We estimated the potential clinical benefit of treating eligible patients with a beta-blocker by extrapolating the treatment effect observed in a previously reported randomized clinical trial.
Of 158 patients undergoing major noncardiac surgery, 67 (42.4%) seemed to be ideal candidates for treatment with perioperative beta-blockers. Of these 67 patients, 25 (37%) received a beta-blocker at some time perioperatively. During the course of a year, we estimate that between 560 and 801 patients who do not receive beta-blockers might benefit from treatment with these medications. Full use of beta-blockers among eligible patients at our institution could result in 62 to 89 fewer deaths each year at an overall cost of $33 661 to $40 210.
There seems to be a large opportunity to improve the quality of care of patients undergoing major noncardiac surgery by increasing the use of beta-blockers in the perioperative period. A clinical practice guideline may be one method to achieve these goals at little cost.
β受体阻滞剂用于接受重大非心脏手术的高危患者时可降低发病率和死亡率，但对于其处方频率知之甚少。临床实践指南是可用于加速研究成果转化为实际应用的工具，可能是改善β受体阻滞剂使用情况的一种方法。在实施任何指南之前，预测其潜在的临床和财务影响很重要。
我们利用行政和病历审查数据，对1999年1个月期间在马萨诸塞州斯普林菲尔德市贝斯州医疗中心接受重大非心脏手术的所有成年患者进行了一项回顾性队列研究。有2个或更多心脏危险因素或有记录的冠状动脉疾病的患者被归类为高危患者，如果没有明显的使用禁忌证，则被认为有资格接受β受体阻滞剂治疗。我们通过推断先前报道的一项随机临床试验中观察到的治疗效果，估计了用β受体阻滞剂治疗符合条件的患者的潜在临床益处。
在158例接受重大非心脏手术的患者中，67例（42.4%）似乎是围手术期使用β受体阻滞剂治疗的理想人选。在这67例患者中，25例（37%）在围手术期的某个时间接受了β受体阻滞剂治疗。我们估计，在一年的时间里，560至801例未接受β受体阻滞剂治疗的患者可能会从这些药物治疗中获益。在我们机构，符合条件的患者充分使用β受体阻滞剂每年可减少62至89例死亡，总成本为33661美元至40210美元。
通过增加围手术期β受体阻滞剂的使用，似乎有很大机会改善接受重大非心脏手术患者的护理质量。临床实践指南可能是一种低成本实现这些目标的方法。
