Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
J Vasc Surg. 2011 May;53(5):1316-1328.e1; discussion 1327-8. doi: 10.1016/j.jvs.2010.10.131. Epub 2011 Feb 21.
To determine if a regional quality improvement effort can increase beta-blocker utilization prior to vascular surgery and decrease the incidence of postoperative myocardial infarction (POMI).
A quality improvement effort to increase perioperative beta blocker utilization was implemented in 2003 at centers participating in the Vascular Study Group of New England (VSGNE). A 90% target was set and feedback given at biannual meetings. Beta blocker utilization (<1 month preoperative versus chronic) and POMI rates were prospectively collected for patients undergoing open abdominal aortic aneurysm (AAA) repair (n = 926) and lower extremity bypass (LEB; n = 2,123) from 2003 through 2008. Predictors of POMI were determined using multivariate logistic regression. Rates of beta blocker administration and POMI were analyzed over time, and across strata of patient risk based on a multivariate model.
Perioperative beta blocker treatment increased from 68% of patients in the first 3 months of 2005 to 88% by the last 3 months of 2008 (P < .001). In 2003, 44% of patients not on chronic beta blockers were treated with preoperative beta blockers; by 2008, 78% of patients not on chronic beta blockers were started perioperatively on these medications (P < .001). Beta blocker utilization increased across all centers and surgeons participating during the study period, and increased in patients of low, medium, and high cardiac risk. However, the rate of POMI did not change over time (5.2% in 2003, 5.5% in 2008; P = .876), although a trend towards lower POMI rate was seen in patients on preoperative beta blockers (4.4% in 2003-2005, 2.6% in 2006-2008; P = .43). In multivariable modeling we found that age >70 (odds ratio [OR], 2.1), positive stress test (OR, 2.2), congestive heart failure (CHF; OR, 1.7), chronic beta blocker administration (OR, 1.7), resting heart rate <70 (OR, 1.8), and diabetes (OR, 1.6) were associated with POMI. Resting heart rate was similar for patients on chronic (67), preoperative (70), and no beta blockers (70; P = .521).
Our regional quality improvement effort successfully increased perioperative beta blocker utilization. However, this was not associated with reduced rates of POMI or resting heart rate. While this demonstrates the effectiveness of regional quality improvement efforts in changing practice patterns, further work is necessary to more precisely identify those patients who will benefit from beta blockade at the time of vascular surgery.
确定区域质量改进工作是否可以增加血管外科手术前β受体阻滞剂的使用，并降低术后心肌梗死（POMI）的发生率。
2003 年，新英格兰血管研究小组（VSGNE）参与的中心实施了一项提高围手术期β受体阻滞剂使用率的质量改进工作。设定了 90%的目标，并在每两年一次的会议上提供反馈。前瞻性收集了 2003 年至 2008 年期间接受开放性腹主动脉瘤（AAA）修复（n=926）和下肢旁路（LEB；n=2123）手术患者的β受体阻滞剂使用情况（<1 个月术前与慢性）和 POMI 发生率。使用多变量逻辑回归确定 POMI 的预测因素。分析了β受体阻滞剂给药率和 POMI 随时间的变化，并根据多变量模型分析了基于患者风险分层的情况。
围手术期β受体阻滞剂治疗从 2005 年的前 3 个月的 68%增加到 2008 年的最后 3 个月的 88%（P<0.001）。2003 年，44%未服用慢性β受体阻滞剂的患者接受了术前β受体阻滞剂治疗；到 2008 年，78%未服用慢性β受体阻滞剂的患者开始在围手术期使用这些药物（P<0.001）。β受体阻滞剂的使用率在整个研究期间所有参与的中心和外科医生中均有所增加，并且在低、中、高心脏风险的患者中也有所增加。然而，POMI 的发生率并没有随时间变化（2003 年为 5.2%，2008 年为 5.5%；P=0.876），尽管术前使用β受体阻滞剂的患者的 POMI 发生率呈下降趋势（2003-2005 年为 4.4%，2006-2008 年为 2.6%；P=0.43）。在多变量模型中，我们发现年龄>70 岁（比值比[OR]，2.1）、阳性应激试验（OR，2.2）、充血性心力衰竭（CHF；OR，1.7）、慢性β受体阻滞剂治疗（OR，1.7）、静息心率<70（OR，1.8）和糖尿病（OR，1.6）与 POMI 相关。慢性（67）、术前（70）和无β受体阻滞剂（70）的患者静息心率相似（P=0.521）。
我们的区域质量改进工作成功地增加了围手术期β受体阻滞剂的使用。然而，这与 POMI 或静息心率降低无关。虽然这表明区域质量改进工作在改变实践模式方面的有效性，但仍需要进一步努力，以更准确地确定那些在血管手术时将从β受体阻滞剂治疗中受益的患者。
