Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
Am J Med. 2013 Jan;126(1):74.e1-9. doi: 10.1016/j.amjmed.2012.02.025. Epub 2012 Aug 24.
There have been substantial improvements in the use of evidence-based, guideline-recommended therapies for patients with acute myocardial infarction. Nevertheless, some gaps, disparities, and variations in use remain. To understand how such gaps in recommended care may be narrowed further, it may be useful to determine those factors associated with lessened adherence to guideline-based care.
The Get with the Guidelines-Coronary Artery Disease registry measured adherence with 6 performance measures (aspirin within 24 hours, discharge on aspirin and beta-blockers, patients with low ejection fraction discharged on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, smoking cessation counseling, use of lipid-lowering medications) in 148,654 patients with acute myocardial infarction between 2002 and 2009. Logistic multivariable regression models using generalized estimating equations were utilized to identify patient and hospital characteristics associated with adherence to each of 6 measures, and to a summary score of performance for all measures, in eligible patients.
We identified 10 variables that were associated significantly with either greater adherence (hypertension, hyperlipidemia, hospital with full interventional capabilities, calendar year) or worse adherence (age, female sex, congestive heart failure, chronic renal insufficiency, atrial fibrillation, chronic dialysis) in at least 4 of the 6 treatment adherence models, as well as the summary score adherence model. Age, sex, and calendar year were significant in all models.
Use of evidence-based acute myocardial infarction treatments remains less than ideal for certain high-risk populations. The close correlations among factors associated with underperformance highlights the potential for specifically targeting and tailoring quality improvement interventions.
在急性心肌梗死患者中，使用循证医学、指南推荐的疗法已经取得了实质性的进展。然而，在使用方面仍存在一些差距、差异和变化。为了进一步了解如何缩小这些推荐治疗方面的差距，确定与降低指南推荐护理依从性相关的因素可能会有所帮助。
Get with the Guidelines-Coronary Artery Disease 登记处测量了 148654 例急性心肌梗死患者在 2002 年至 2009 年期间 6 项绩效指标（阿司匹林在 24 小时内、出院时使用阿司匹林和β受体阻滞剂、射血分数低的患者出院时使用血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂、戒烟咨询、使用降脂药物）的依从性。使用广义估计方程的逻辑多变量回归模型，确定了与每一项 6 项措施的依从性以及所有措施的绩效综合评分相关的患者和医院特征，在符合条件的患者中。
我们确定了 10 个变量，这些变量与至少 4 项治疗依从性模型中的更好的依从性（高血压、高血脂、具有完整介入能力的医院、日历年度）或更差的依从性（年龄、女性、充血性心力衰竭、慢性肾功能不全、心房颤动、慢性透析）显著相关，以及综合评分的依从性模型。年龄、性别和日历年度在所有模型中均有显著意义。
某些高危人群对循证急性心肌梗死治疗的使用仍不理想。与表现不佳相关的因素之间的密切相关性突出了针对和定制质量改进干预措施的潜力。
