医院心脏管理与急性心肌梗死患者结局的关系。

Association between hospital cardiac management and outcomes for acute myocardial infarction patients.

机构信息

Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.

出版信息

Med Care. 2010 Feb;48(2):157-65. doi: 10.1097/MLR.0b013e3181bd4da7.

DOI:10.1097/MLR.0b013e3181bd4da7

PMID:19927014

Abstract

BACKGROUND

Randomized trials have shown that medical and interventional therapies improve outcomes for acute myocardial infarction (AMI) patients. The extent to which hospital quality improvement translates into better patient outcomes is unclear.

OBJECTIVES

To determine hospital cardiac management markers associated with improved outcomes. RESEARCH DESIGN, SUBJECTS: Population-based longitudinal cohort study of 98,115 adults hospitalized with first episode of AMI during 2000 to 2006 in 77 Ontario hospitals with >50 annual AMI admissions.

MEASURES

Rates of 30-day and 1-year mortality, readmissions for AMI or death, and major cardiac events (readmissions for AMI, angina, heart failure, or death) within 6 months, according to index hospital cardiac management markers, including appropriate initial emergency department (ED) assessment (rate of high acuity triage) high-acuity and intensity of interventional (30-day cardiac catheterization rate) and medical (discharge statin prescribing rate) therapy.

RESULTS

Thirty-day risk-adjusted mortality varied 2.3-fold (7.2%-16.9%) and major cardiac events rates varied 2-fold (18.2%-35.6%) across hospitals in 2006. Patients admitted to hospitals with the highest versus lowest rates of combined medical and interventional management had lower rates of 30-day mortality (adjusted relative rate [aRR] = 0.84, 95% CI, 0.78-0.91), 1-year mortality (aRR = 0.86, 0.81-0.91), AMI readmissions or death (aRR = 0.74, 0.69-0.78), and major cardiac event (aRR = 0.65, 0.61-0.68). Patients admitted to EDs with the highest rates of appropriate initial assessment had lower 30-day (aRR = 0.93, 0.88-0.98) and 1-year mortality (aRR = 0.96, 0.93-1.00).

CONCLUSIONS

Hospitals with higher levels of both medical and interventional management and higher quality initial ED assessment had better outcomes. Readmissions were particularly sensitive to care processes. In the face of the unwarranted variations in outcomes across hospitals, strategies that promote better ED and inpatient management of AMI patients are needed.

摘要

背景

随机试验表明，医疗和介入治疗可改善急性心肌梗死（AMI）患者的预后。医院质量改进在多大程度上转化为更好的患者结局尚不清楚。

目的

确定与改善结局相关的医院心脏管理标志物。

研究设计、地点：本研究为基于人群的纵向队列研究，纳入了 2000 年至 2006 年期间在安大略省 77 家每年至少收治 50 例 AMI 患者的医院中因首次 AMI 住院的 98115 例成年人。

测量指标

根据指数医院心脏管理标志物，包括初始急诊科（ED）评估（高敏分诊率）、介入（30 天内心脏导管检查率）和药物（出院时开具他汀类药物的比率）治疗的适当初始 ED 评估、适当初始 ED 评估、介入和药物治疗的高敏性和强度，评估 30 天和 1 年死亡率、因 AMI 或死亡再次入院、以及 6 个月内主要心脏事件（因 AMI、心绞痛、心力衰竭或死亡再次入院）的发生率。

结果

2006 年，各医院 30 天风险调整死亡率差异高达 2.3 倍（7.2%~~16.9%），主要心脏事件发生率差异高达 2 倍（18.2%~~35.6%）。与接受药物和介入治疗管理水平最低的医院相比，接受药物和介入治疗管理水平最高的医院 30 天死亡率（调整后的相对比率[aRR]，0.84；95%CI，0.78~~0.91）、1 年死亡率（aRR，0.86；0.81~~0.91）、因 AMI 再次入院或死亡（aRR，0.74；0.69~~0.78）和主要心脏事件（aRR，0.65；0.61~~0.68）的发生率较低。在 ED 接受初始评估的比例最高的患者，30 天死亡率（aRR，0.93；0.88~~0.98）和 1 年死亡率（aRR，0.96；0.93~~1.00）较低。