Ho P Michael, Prochazka Allan V, Magid David J, Sales Anne E, Grunwald Gary K, Hammermeister Karl E, Rumsfeld John S
Department of Medicine, University of Colorado Health Sciences Center, Denver, CO, USA.
BMC Cardiovasc Disord. 2006 Feb 9;6:6. doi: 10.1186/1471-2261-6-6.
Hyperlipidemia and hypertension are well-established risk factors for recurrent cardiovascular events among patients with ischemic heart disease (IHD). Despite national recommendations, concordance with guidelines for LDL cholesterol and blood pressure remains inadequate. The objectives of this study were to 1) determine concordance rates with LDL cholesterol and BP recommendations; and 2) identify patient factors, processes and structures of care associated with guideline concordance among VA IHD patients.
This was a cross sectional study of veterans with IHD from 8 VA hospitals. Outcomes were concordance with LDL guideline recommendations (LDL<100 mg/dl), and BP recommendations (<140/90 mm Hg). Cumulative logit and hierarchical logistic regression analyses were performed to identify patient factors, processes, and structures of care independently associated with guideline concordance.
Of 14,114 veterans with IHD, 55.7% had hypertension, 71.5% had hyperlipidemia, and 41.6% had both conditions. Guideline concordance for LDL and BP were 38.9% and 53.4%, respectively. However, only 21.9% of the patients achieved both LDL <100 mg/dl and BP <140/90 mm Hg. In multivariable analyses, patient factors including older age and the presence of vascular disease were associated with worse guideline concordance. In contrast, diabetes was associated with better guideline concordance. Several process of care variables, including higher number of outpatient visits, higher number of prescribed medications, and a recent cardiac hospitalization were associated with better guideline concordance. Among structures of care, having on-site cardiology was associated with a trend towards better guideline concordance.
Guideline concordance with secondary prevention measures among IHD patients remains suboptimal. It is hoped that the findings of this study can serve as an impetus for quality improvement efforts to improve upon secondary prevention measures and reduce the morbidity and mortality of patients with known IHD.
高脂血症和高血压是缺血性心脏病（IHD）患者心血管事件复发的既定危险因素。尽管有国家建议，但低密度脂蛋白胆固醇和血压与指南的一致性仍然不足。本研究的目的是：1）确定低密度脂蛋白胆固醇和血压建议的一致性率；2）确定与退伍军人事务部（VA）IHD患者指南一致性相关的患者因素、护理过程和护理结构。
这是一项对来自8家VA医院的IHD退伍军人的横断面研究。结果指标为与低密度脂蛋白指南建议（低密度脂蛋白<100mg/dl）和血压建议（<140/90mmHg）的一致性。进行累积logit分析和分层逻辑回归分析，以确定与指南一致性独立相关的患者因素、护理过程和护理结构。
在14114例IHD退伍军人中，55.7%患有高血压，71.5%患有高脂血症，41.6%同时患有这两种疾病。低密度脂蛋白和血压的指南一致性分别为38.9%和53.4%。然而，只有21.9%的患者实现了低密度脂蛋白<100mg/dl且血压<140/90mmHg。在多变量分析中，包括年龄较大和存在血管疾病在内的患者因素与较差的指南一致性相关。相比之下，糖尿病与较好的指南一致性相关。几个护理过程变量，包括门诊就诊次数较多、处方药物数量较多以及近期心脏住院治疗，与较好的指南一致性相关。在护理结构方面，有现场心脏病学服务与更好的指南一致性趋势相关。
IHD患者二级预防措施的指南一致性仍然不理想。希望本研究结果能够推动质量改进工作，以改善二级预防措施，降低已知IHD患者的发病率和死亡率。
