Turner Barbara J, Hollenbeak Christopher S, Weiner Mark, Ten Have Thomas, Tang Simon S K
University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104-6021, USA.
Ann Intern Med. 2008 Apr 15;148(8):578-86. doi: 10.7326/0003-4819-148-8-200804150-00002.
Quality-of-care assessment at a single visit can be affected by whether a patient's comorbid conditions are related or unrelated to a specific measure.
To examine the association of unrelated comorbid conditions with treatment of uncontrolled hypertension in primary care visits.
Examination of a database derived from electronic medical records collected during routine care of a cohort of primary care patients.
6 primary care practices in Philadelphia, Pennsylvania.
15,459 patients with uncontrolled hypertension who made 70,557 visits to 200 clinicians from January 2004 through December 2006.
Intensification of any antihypertensive treatment before the next visit was assessed. Patient and clinician information were obtained from electronic medical records and administrative data. Unrelated comorbid conditions included 28 conditions, such as arthritis and emphysema, whereas related comorbid conditions included vascular diseases. Generalized estimating equation logistic regression models were used to adjust for patient, health care, and provider characteristics and for clustering. Variation in the effect of unrelated comorbid conditions was examined at the visit, patient, and provider level.
At study visits, patients had a mean of 2.2 (SD, 1.8) unrelated comorbid conditions. The adjusted odds of treatment intensification decreased with the number of unrelated comorbid conditions, from 0.85 (95% CI, 0.80 to 0.90) for 1 to 0.59 (CI, 0.51 to 0.69) for 7 or more versus none. The relationship between treatment intensification and unrelated comorbid conditions persisted at the visit, patient, and provider levels (P < 0.001).
The reasons for not intensifying treatments are unknown. The recorded blood pressure may be inaccurate. Physicians may vary in their recording of comorbid conditions.
Patients with more unrelated comorbid conditions were less likely to have uncontrolled hypertension addressed at a visit. The effect of different types of comorbid conditions on meeting quality-of-care measures merits further investigation.
单次就诊时的医疗质量评估可能会受到患者合并症与特定指标是否相关的影响。
研究在初级保健就诊中，不相关合并症与未控制高血压治疗之间的关联。
对一组初级保健患者在常规护理期间收集的电子病历数据库进行分析。
宾夕法尼亚州费城的6家初级保健机构。
2004年1月至2006年12月期间，15459例未控制高血压患者，共就诊70557次。
评估下次就诊前任何降压治疗的强化情况。患者和临床医生信息来自电子病历和管理数据。不相关合并症包括28种疾病，如关节炎和肺气肿，而相关合并症包括血管疾病。使用广义估计方程逻辑回归模型对患者、医疗保健和提供者特征以及聚类进行调整。在就诊、患者和提供者层面检查不相关合并症影响的差异。
在研究就诊时，患者平均有2.2种（标准差1.8）不相关合并症。治疗强化的校正比值随不相关合并症数量的增加而降低，从无合并症时的1种合并症的0.85（95%可信区间，0.80至0.90）降至7种或更多合并症时的0.59（可信区间，0.51至0.69）。治疗强化与不相关合并症之间的关系在就诊、患者和提供者层面均持续存在（P<0.001）。
未强化治疗的原因尚不清楚。记录的血压可能不准确。医生对合并症的记录可能存在差异。
合并更多不相关合并症的患者在就诊时解决未控制高血压问题的可能性较小。不同类型合并症对达到医疗质量指标的影响值得进一步研究。
