Granger Christopher B, Steg Philippe Gabriel, Peterson Eric, López-Sendón José, Van de Werf Frans, Kline-Rogers Eva, Allegrone Jeanna, Dabbous Omar H, Klein Werner, Fox Keith A A, Eagle Kim A
Duke University Medical Center, Durham, NC, USA.
Am J Med. 2005 Aug;118(8):858-65. doi: 10.1016/j.amjmed.2005.01.070.
To identify patient and health care factors which are related to the use of medical treatments that comprise quality measures and to assess the relation of these measures with mortality.
The study sample consisted of 20 140 patients with acute coronary syndromes from the international GRACE registry. Multivariable logistic regression modeling was used to determine predictors of quality performance. Quality indicators were use of aspirin and beta-blockers within 24 hours and at hospital discharge, use of angiotensin-converting enzyme (ACE) inhibitors at discharge, and in-hospital mortality.
Use of medications in eligible patients at discharge ranged from 73% for ACE inhibitors to 93% for aspirin. High-risk features (eg, heart failure, older age) were related to failure to use aspirin and beta-blockers. Being at a teaching hospital and care by a cardiologist were associated with better use of aspirin and beta-blockers. Coronary artery bypass surgery was associated with failure to use ACE inhibitors and aspirin. When hospitals were divided into quartiles of quality performance, adjusted in-hospital mortality was 4.1% in the top versus 5.6% in the bottom quartile, representing a 27% (95% confidence interval: 11% to 42%) lower relative mortality.
Identification of factors associated with failure to use proven treatments, including high-risk groups that would derive particular benefit from effective therapies, provides an opportunity to focus quality improvement interventions. The association of lower hospital mortality with better use of selected medical treatments supports their measurement to improve quality of care.
确定与包含质量指标的医学治疗方法使用相关的患者和医疗保健因素，并评估这些指标与死亡率的关系。
研究样本包括来自国际GRACE注册研究的20140例急性冠状动脉综合征患者。采用多变量逻辑回归模型确定质量表现的预测因素。质量指标包括24小时内及出院时阿司匹林和β受体阻滞剂的使用、出院时血管紧张素转换酶（ACE）抑制剂的使用以及住院死亡率。
符合条件的患者出院时药物使用率从ACE抑制剂的73%到阿司匹林的93%不等。高风险特征（如心力衰竭、高龄）与未使用阿司匹林和β受体阻滞剂有关。在教学医院就诊及由心脏病专家治疗与更好地使用阿司匹林和β受体阻滞剂有关。冠状动脉搭桥手术与未使用ACE抑制剂和阿司匹林有关。当医院被分为质量表现四分位数时，调整后的住院死亡率在最高四分位数组为4.1%，在最低四分位数组为5.6%，相对死亡率降低了27%（95%置信区间：从11%至42%）。
识别与未使用已证实治疗方法相关的因素，包括能从有效治疗中特别受益的高风险群体，为聚焦质量改进干预措施提供了机会。较低的医院死亡率与更好地使用特定医学治疗方法之间的关联支持将这些指标用于改善医疗质量。
