Laskey Warren, Spence Nathan, Zhao Xin, Mayo Rebecca, Taylor Robert, Cannon Christopher P, Hernandez Adrian F, Peterson Eric D, Fonarow Gregg C
Division of Cardiology, Department of Internal Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM 87131, USA.
Crit Pathw Cardiol. 2010 Mar;9(1):1-7. doi: 10.1097/HPC.0b013e3181cdb5a5.
Geographic differences in the delivery of guideline-driven care following acute myocardial infarction have been described. The effect of hospital participation in a national performance improvement program on regional variation in quality of care and in-hospital outcomes for acute coronary syndromes (ACS) is unknown.
We evaluated the variation in conformity to the American Heart Association Get With The Guidelines-Coronary Artery Disease Program quality measures across 4 geographic regions (Northeast, Midwest, South, and East) in 161,236 patients admitted for ACS to 436 Get With The Guidelines hospitals. We evaluated 6 measures (aspirin within 24 hours, aspirin at discharge, ACEI or ARB therapy for left ventricular systolic dysfunction, beta-blocker at discharge, lipid-lowering medication for qualified patients, smoking cessation advice); a binary "all-or-none" process performance measure (primary outcome); an "opportunity-based" overall composite score (secondary outcome); in-hospital length of stay, and in-hospital mortality. Multivariable logistic regression was performed to test the associations between performance measures and short-term outcomes and geographic region.
Data were collected from January 2, 2000 to January 2, 2008. There was no significant regional variation in either the "all-or-none" (Northeast: 79.3%; Midwest: 83.2%; South: 78.9%; West: 81.6%) or "opportunity-based" (Northeast: 91.9%; Midwest: 93.6%; South: 91.5%; West: 92.6%) composite performance measures. Both performance measures exhibited significant improvement with participation time irrespective of region. In-hospital mortality was similar among regions. Adjusted hospital length of stay was significantly shorter in the Midwest.
Quality improvement program participation may help to facilitate high quality, consistent care for patients with ACS.
急性心肌梗死后遵循指南驱动治疗的地域差异已有报道。医院参与国家质量改进项目对急性冠脉综合征（ACS）护理质量和院内结局区域差异的影响尚不清楚。
我们评估了161236例因ACS入住436家参与“遵循指南”项目医院的患者，在4个地理区域（东北、中西部、南部和西部）遵循美国心脏协会“遵循指南-冠心病项目”质量指标的差异。我们评估了6项指标（24小时内使用阿司匹林、出院时使用阿司匹林、对左心室收缩功能障碍患者使用ACEI或ARB治疗、出院时使用β受体阻滞剂、对符合条件的患者使用降脂药物、戒烟建议）；一个二元“全或无”过程绩效指标（主要结局）；一个“基于机会”的总体综合评分（次要结局）；住院时间和院内死亡率。进行多变量逻辑回归以检验绩效指标与短期结局及地理区域之间的关联。
数据收集时间为2000年1月2日至2008年1月2日。“全或无”（东北：79.3%；中西部：83.2%；南部：78.9%；西部：81.6%）或“基于机会”（东北：91.9%；中西部：93.6%；南部：91.5%；西部：92.6%）综合绩效指标均无显著区域差异。无论区域如何，两项绩效指标均随参与时间有显著改善。各区域间院内死亡率相似。中西部地区调整后的住院时间显著更短。
参与质量改进项目可能有助于为ACS患者提供高质量、一致的护理。
