考察急性心肌梗死（AMI）的指南一致护理：以住院后急性和长期护理（PAC/LTC）居民为例。

Examining guideline-concordant care for acute myocardial infarction (AMI): the case of hospitalized post-acute and long-term care (PAC/LTC) residents.

机构信息

Colorado Research to Improve Care Coordination, Veterans Affairs (VA) Eastern Colorado Healthcare System, Denver, Colorado, USA.

出版信息

J Hosp Med. 2010 Feb;5(2):E3-E10. doi: 10.1002/jhm.622.

DOI:10.1002/jhm.622

PMID:20104634

Abstract

BACKGROUND

Previous studies have examined differences in care for acute myocardial infarction (AMI) according to patient characteristics such as age, gender, or insurance, but little attention has been given to whether admission source is related to guideline adherence.

OBJECTIVE

To investigate: (1) the use of aspirin and reperfusion in the care of post-acute/long-term care (PAC/LTC) patients who are hospitalized for AMI, and (2) 30-day mortality associated with these treatments.

DESIGN

Secondary examination of data from the Cooperative Cardiovascular Project (CCP) national baseline data.

SETTING

A total of 4013 U.S. hospitals.

SUBJECTS

Patients hospitalized with a confirmed AMI admitted from PAC/LTC (n = 8151) or community-dwelling (n = 120,032) settings.

MEASUREMENTS

Early administration of aspirin and reperfusion via either thrombolysis or percutaneous intervention.

RESULTS

PAC/LTC patients were less likely to receive treatment for AMI, even after adjustment for multiple variables associated with treatment choice. Differences persisted with additional econometric adjustment using seemingly-unrelated regression. Multivariable logistic regression results indicated that aspirin was related to improved 30-day survival for both PAC/LTC and community admissions (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.43-0.58 for PAC/LTC, and OR, 0.57; 95% CI, 0.54-0.60 for community). Reperfusion was associated with higher ORs for mortality for eligible patients admitted from community setting (OR, 1.24; 95% CI, 1.13-1.35), but ideally-eligible candidates had lower ORs for mortality (OR, 0.58; 95% CI, 0.35-0.95 for PAC/LTC, and OR, 0.74; 95% CI, 0.68-0.81 for community).

CONCLUSIONS

Patients transferred from PAC/LTC settings were less likely to receive early treatment for AMI than other patients. Future trials should inform which guidelines are applicable to PAC/LTC patients.

摘要

背景

先前的研究已经考察了根据患者特征（如年龄、性别或保险）对急性心肌梗死（AMI）护理的差异，但很少关注入院来源是否与指南遵循有关。

目的

调查：（1）接受长期护理/疗养院（PAC/LTC）治疗后因 AMI 住院的患者接受阿司匹林和再灌注治疗的情况，以及（2）这些治疗与 30 天死亡率的关系。

设计

对来自合作心血管项目（CCP）全国基线数据的二次检查。

设置

4013 家美国医院。

患者

从 PAC/LTC（n=8151）或社区居住（n=120032）环境入院的确诊 AMI 住院患者。

测量

早期给予阿司匹林和通过溶栓或经皮介入进行再灌注。

结果

PAC/LTC 患者接受 AMI 治疗的可能性较小，即使在调整了与治疗选择相关的多个变量后也是如此。在使用似乎不相关的回归进行额外的计量经济学调整后，差异仍然存在。多变量逻辑回归结果表明，阿司匹林与 PAC/LTC 和社区入院患者的 30 天生存率提高有关（优势比[OR]，0.50；95%置信区间[CI]，0.43-0.58 为 PAC/LTC，OR，0.57；95%CI，0.54-0.60 为社区）。对于从社区环境入院的合格患者，再灌注与死亡率的更高 OR 相关（OR，1.24；95%CI，1.13-1.35），但理想合格患者的死亡率 OR 较低（OR，0.58；95%CI，0.35-0.95 为 PAC/LTC，OR，0.74；95%CI，0.68-0.81 为社区）。