Higashi Takahiro, Shekelle Paul G, Adams John L, Kamberg Caren J, Roth Carol P, Solomon David H, Reuben David B, Chiang Lillian, MacLean Catherine H, Chang John T, Young Roy T, Saliba Debra M, Wenger Neil S
RAND Health, Santa Monica, California 90407-2138, USA.
Ann Intern Med. 2005 Aug 16;143(4):274-81. doi: 10.7326/0003-4819-143-4-200508160-00008.
Although assessment of the quality of medical care often relies on measures of process of care, the linkage between performance of these process measures during usual clinical care and subsequent patient outcomes is unclear.
To examine the link between the quality of care that patients received and their survival.
Observational cohort study.
Two managed care organizations.
Community-dwelling high-risk patients 65 years of age or older who were continuously enrolled in the managed care organizations from 1 July 1998 to 31 July 1999.
Quality of care received by patients (as measured by a set of quality indicators covering 22 clinical conditions) and their survival over the following 3 years.
The 372 vulnerable older patients were eligible for a mean of 21 quality indicators (range, 8 to 54) and received, on average, 53% of the care processes prescribed in quality indicators (range, 27% to 88%). Eighty-six (23%) persons died during the 3-year follow-up. There was a graded positive relationship between quality score and 3-year survival. After adjustment for sex, health status, and health service use, quality score was not associated with mortality for the first 500 days, but a higher quality score was associated with lower mortality after 500 days (hazard ratio, 0.64 [95% CI, 0.49 to 0.84] for a 10% higher quality score).
The observational design limits causal inference regarding the effect of quality of care on survival.
Better performance on process quality measures is strongly associated with better survival among community-dwelling vulnerable older adults.
尽管医疗质量评估通常依赖于医疗过程的衡量指标，但这些过程指标在常规临床护理中的表现与随后的患者结局之间的联系尚不清楚。
研究患者接受的护理质量与其生存之间的联系。
观察性队列研究。
两个管理式医疗组织。
1998年7月1日至1999年7月31日期间持续参加管理式医疗组织的65岁及以上社区居住高危患者。
患者接受的护理质量（通过一组涵盖22种临床情况的质量指标衡量）及其在接下来3年中的生存情况。
372名脆弱的老年患者平均符合21项质量指标（范围为8至54项），平均接受了质量指标规定的53%的护理过程（范围为27%至88%）。在3年随访期间，86人（23%）死亡。质量得分与3年生存率之间存在分级正相关。在对性别、健康状况和医疗服务使用情况进行调整后，质量得分在前500天与死亡率无关，但质量得分越高，500天后死亡率越低（质量得分每提高10%，风险比为0.64 [95% CI，0.49至0.84]）。
观察性设计限制了关于护理质量对生存影响的因果推断。
在过程质量指标上表现更好与社区居住的脆弱老年人更好的生存密切相关。
