Burwen Dale R, Galusha Deron H, Lewis Jennifer M, Bedinger Marjorie R, Radford Martha J, Krumholz Harlan M, Foody JoAnne Micale
Centers for Medicare & Medicaid Services, Baltimore, MD, USA.
Arch Intern Med. 2003 Jun 23;163(12):1430-9. doi: 10.1001/archinte.163.12.1430.
National efforts have focused attention on quality of care, but relatively little is known about whether, and to what extent, improvement has occurred during this recent period. Furthermore, the variability of the recent change over time is not known.
We sought to determine national and state trends in quality of care for Medicare patients hospitalized with acute myocardial infarction (AMI) between 1994-1995 (n = 234754 discharges) and 1998-1999 (n = 35713 discharges) as part of the Centers for Medicare & Medicaid Services (CMS) National AMI Project. We assessed change in evidence-based, guideline-recommended processes of care.
Nationally, among patients without contraindications to therapy, discharge beta-blocker prescription increased by 20.5 percentage points (50.3% to 70.7%); early administration of beta-blocker increased by 17.4 percentage points (51.1% to 68.4%); discharge angiotensin-converting enzyme inhibitor prescription for systolic dysfunction increased by 8.0 percentage points (62.8% to 70.8%); early administration of aspirin increased by 6.6 percentage points (76.4% to 82.9%); and aspirin prescribed at discharge increased by 5.6 percentage points (77.3% to 82.9%) (P<.001 for all categories). Smoking cessation counseling decreased by 3.6 percentage points (40.8% to 37.2%; P<.001). Rates of acute reperfusion therapy did not significantly change (59.2% to 60.6%; P =.35). The median time from hospital arrival to initiation of thrombolytic therapy decreased by 7 minutes (P<.001); and the median time from hospital arrival to initiation of primary percutaneous transluminal coronary angioplasty decreased by 12 minutes (P =.09).
During this 4-year period, quality of care for AMI improved, but substantial variation was observed at both time points. While meaningful population-based improvement has been achieved, ample opportunities for improvement exist. Further work is required to elucidate the strategies associated with improvements in quality of care.
国家层面的努力已将注意力集中在医疗质量上，但对于在最近这段时间内是否以及在何种程度上实现了改善，人们了解得相对较少。此外，近期随时间变化的差异情况也尚不清楚。
作为医疗保险和医疗补助服务中心（CMS）国家急性心肌梗死（AMI）项目的一部分，我们试图确定1994 - 1995年（n = 234754例出院病例）和1998 - 1999年（n = 35713例出院病例）期间，医疗保险患者因急性心肌梗死住院治疗的全国及各州医疗质量趋势。我们评估了基于证据、指南推荐的治疗过程中的变化。
在全国范围内，在无治疗禁忌证的患者中，出院时β受体阻滞剂处方率增加了20.5个百分点（从50.3%增至70.7%）；β受体阻滞剂的早期使用增加了17.4个百分点（从51.1%增至68.4%）；因收缩功能障碍出院时使用血管紧张素转换酶抑制剂的处方率增加了8.0个百分点（从62.8%增至70.8%）；阿司匹林的早期使用增加了6.6个百分点（从76.4%增至82.9%）；出院时开具阿司匹林的比例增加了5.6个百分点（从77.3%增至82.9%）（所有类别P <.001）。戒烟咨询减少了3.6个百分点（从40.8%降至37.2%；P <.001）。急性再灌注治疗率无显著变化（从59.2%增至60.6%；P =.35）。从入院到开始溶栓治疗的中位时间减少了7分钟（P <.001）；从入院到开始直接经皮冠状动脉腔内血管成形术的中位时间减少了12分钟（P =.09）。
在这4年期间，急性心肌梗死的医疗质量有所改善，但在两个时间点均观察到了显著差异。虽然已在基于人群的层面上实现了有意义的改善，但仍有大量改进机会。需要进一步开展工作以阐明与医疗质量改善相关的策略。
