Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut 06510, USA.
J Am Coll Cardiol. 2012 Oct 9;60(15):1402-9. doi: 10.1016/j.jacc.2012.07.011. Epub 2012 Sep 12.
This study sought to determine hospital variation in the use of positive inotropic agents in patients with heart failure.
Clinical guidelines recommend targeted use of positive inotropic agents in highly selected patients, but data are limited and the recommendations are not specific.
We analyzed data from 376 hospitals including 189,948 hospitalizations for heart failure from 2009 through 2010. We used hierarchical logistic regression models to estimate hospital-level risk-standardized rates of inotrope use and risk-standardized in-hospital mortality rates.
The risk-standardized rates of inotrope use ranged across hospitals from 0.9% to 44.6% (median: 6.3%, interquartile range: 4.3% to 9.2%). We identified various hospital patterns based on the type of agents: dobutamine-predominant (29% of hospitals), dopamine-predominant (25%), milrinone-predominant (1%), mixed dobutamine and dopamine pattern (32%), and mixed pattern including all 3 agents (13%). When studying the factors associated with interhospital variation, the best model performance was with the hierarchical generalized linear models that adjusted for patient case mix and an individual hospital effect (receiver operating characteristic curves from 0.77 to 0.88). The intraclass correlation coefficients of the hierarchical generalized linear models (0.113 for any inotrope) indicated that a noteworthy proportion of the observed variation was related to an individual institutional effect. Hospital rates or patterns of use were not associated with differences in length of stay or risk-standardized mortality rates.
We found marked differences in the use of inotropic agents for heart failure patients among a diverse group of hospitals. This variability, occurring in the context of little clinical evidence, indicates an urgent need to define the appropriate use of these medications.
本研究旨在确定心力衰竭患者中使用正性肌力药物的医院差异。
临床指南建议在高度选择的患者中靶向使用正性肌力药物，但数据有限，且建议不具体。
我们分析了来自 376 家医院的数据，包括 2009 年至 2010 年期间 189948 例心力衰竭住院患者的数据。我们使用分层逻辑回归模型来估计医院水平的风险标准化正性肌力药物使用率和风险标准化住院死亡率。
正性肌力药物的风险标准化使用率在医院之间的范围从 0.9%到 44.6%（中位数：6.3%，四分位距：4.3%至 9.2%）。我们根据药物类型确定了各种医院模式：多巴酚丁胺为主（29%的医院）、多巴胺为主（25%）、米力农为主（1%）、混合多巴酚丁胺和多巴胺模式（32%）以及包括所有 3 种药物的混合模式（13%）。在研究与医院间变异相关的因素时，性能最佳的模型是调整患者病例组合和单个医院效应的分层广义线性模型（接受者操作特征曲线从 0.77 到 0.88）。分层广义线性模型的组内相关系数（任何正性肌力药物的 0.113）表明，观察到的变异中有相当一部分与单个机构效应有关。医院使用率或使用模式与住院时间或风险标准化死亡率的差异无关。
我们在一组多样化的医院中发现心力衰竭患者使用正性肌力药物存在显著差异。这种差异发生在临床证据很少的情况下，表明迫切需要定义这些药物的适当使用。
