心力衰竭患者住院期间的护理流程绩效评估与长期预后。
Process of care performance measures and long-term outcomes in patients hospitalized with heart failure.
机构信息
Center for Clinical and Genetic Economics, Duke University School of Medicine, Durham, NC, USA.
出版信息
Med Care. 2010 Mar;48(3):210-6. doi: 10.1097/MLR.0b013e3181ca3eb4.
BACKGROUND
Recent efforts to improve care for patients hospitalized with heart failure have focused on process-based performance measures. Data supporting the link between current process measures and patient outcomes are sparse.
OBJECTIVE
To examine the relationship between adherence to hospital-level process measures and long-term patient-level mortality and readmission.
RESEARCH DESIGN
Analysis of data from a national clinical registry linked to outcome data from the Centers for Medicare and Medicaid Services (CMS).
SUBJECTS
A total of 22,750 Medicare fee-for-service beneficiaries enrolled in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure between March 2003 and December 2004.
MEASURES
Mortality at 1 year; cardiovascular readmission at 1 year; and adherence to hospital-level process measures, including discharge instructions, assessment of left ventricular function, prescription of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker at discharge, prescription of beta-blockers at discharge, and smoking cessation counseling for eligible patients.
RESULTS
Hospital conformity rates ranged from 52% to 86% across the 5 process measures. Unadjusted overall 1-year mortality and cardiovascular readmission rates were 33% and 40%, respectively. In covariate-adjusted analyses, the CMS composite score was not associated with 1-year mortality (hazard ratio, 1.00; 95% confidence interval, 0.98-1.03; P = 0.91) or readmission (hazard ratio, 1.01; 95% confidence interval, 0.99-1.04; P = 0.37). Current CMS process measures were not independently associated with mortality, though prescription of beta-blockers at discharge was independently associated with lower mortality (hazard ratio, 0.94; 95% confidence interval, 0.90-098; P = 0.004).
CONCLUSION
Hospital process performance for heart failure as judged by current CMS measures is not associated with patient outcomes within 1 year of discharge, calling into question whether existing CMS metrics can accurately discriminate hospital quality of care for heart failure.
背景
最近，改善心力衰竭住院患者护理的努力集中在基于流程的绩效指标上。支持当前流程指标与患者结局之间关联的数据很少。
目的
检查医院级流程指标的遵守情况与患者长期死亡率和再入院率之间的关系。
研究设计
对 2003 年 3 月至 2004 年 12 月期间参与医院心力衰竭患者救生治疗组织计划的 22750 名医疗保险付费服务受益人从全国临床注册中心获取的数据进行分析，并与医疗保险和医疗补助服务中心（CMS）的结局数据相链接。
研究对象
总共 22750 名医疗保险付费服务受益人参加了 2003 年 3 月至 2004 年 12 月期间的医院心力衰竭患者救生治疗组织计划。
测量指标
1 年死亡率；1 年心血管再入院率；以及对医院级流程指标的遵守情况，包括出院指导、左心室功能评估、出院时开血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂、出院时开β受体阻滞剂、以及对符合条件的患者进行戒烟咨询。
结果
5 项流程指标的医院合格率范围为 52%至 86%。未经调整的总体 1 年死亡率和心血管再入院率分别为 33%和 40%。在协变量调整分析中，CMS 综合评分与 1 年死亡率（危险比，1.00；95%置信区间，0.98-1.03；P=0.91）或再入院率（危险比，1.01；95%置信区间，0.99-1.04；P=0.37）无关。当前 CMS 流程指标与死亡率无独立相关性，尽管出院时开β受体阻滞剂与死亡率降低独立相关（危险比，0.94；95%置信区间，0.90-0.98；P=0.004）。
结论
根据当前 CMS 衡量标准，心力衰竭医院流程绩效与出院后 1 年内的患者结局无关，这令人质疑现有的 CMS 指标是否能准确区分心力衰竭的医院护理质量。
Zotero 插件