院内缺血性卒中的护理质量和结局：来自全国遵循指南-卒中的研究结果。
Quality of care and outcomes for in-hospital ischemic stroke: findings from the National Get With The Guidelines-Stroke.
机构信息
From the Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO (E.C., H.W.); VA Boston Healthcare System, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA (D.L.B.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.C., Y.X.); Department of Epidemiology, Michigan State University, East Lansing, MI (M.R.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.S.); and Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, CA (G.C.F.).
出版信息
Stroke. 2014 Jan;45(1):231-8. doi: 10.1161/STROKEAHA.113.003617. Epub 2013 Nov 19.
BACKGROUND AND PURPOSE
Analysis of quality of care for in-hospital stroke has not been previously performed at the national level. This study compares patient characteristics, process measures of quality, and outcomes for in-hospital strokes with those for community-onset strokes in a national cohort.
METHODS
We performed a retrospective cohort study of the Get With The Guidelines-Stroke (GWTG-Stroke) database of The American Heart Association from January 2006 to April 2012, using data from 1280 sites that reported ≥1 in-hospital stroke. Patient characteristics, comorbid illnesses, medications, quality of care measures, and outcomes were analyzed for 21 349 in-hospital ischemic strokes compared with 928 885 community-onset ischemic strokes.
RESULTS
Patients with in-hospital stroke had more thromboembolic risk factors, including atrial fibrillation, prosthetic heart valves, carotid stenosis, and heart failure (P<0.0001), and experienced more severe strokes (median National Institutes of Health Stroke Score 9.0 versus 4.0; P<0.0001). Using GWTG-Stroke achievement measures, the proportion of patients with defect-free care was lower for in-hospital strokes (60.8% versus 82.0%; P<0.0001). After accounting for patient and hospital characteristics, patients with in-hospital strokes were less likely to be discharged home (adjusted odds ratio 0.37; 95% confidence intervals [0.35-0.39]) or be able to ambulate independently at discharge (adjusted odds ratio 0.42; 95% confidence intervals [0.39-0.45]). In-hospital mortality was higher for in-hospital stroke (adjusted odds ratio 2.72; 95% confidence intervals [2.57-2.88]).
CONCLUSIONS
Compared with community-onset ischemic stroke, patients with in-hospital stroke experienced more severe strokes, received lower adherence to process-based quality measures, and had worse outcomes. These findings suggest there is an important opportunity for targeted quality improvement efforts for patients with in-hospital stroke.
背景与目的
既往尚未在全国范围内对住院卒中患者的医疗质量进行分析。本研究通过全国性队列研究，比较了住院卒中患者与社区发病卒中患者的患者特征、质量流程指标和结局。
方法
我们对美国心脏协会的 Get With The Guidelines-Stroke（GWTG-Stroke）数据库进行了回顾性队列研究，纳入 2006 年 1 月至 2012 年 4 月期间来自 1280 个报告至少 1 例住院卒中的站点的数据。分析了 21349 例住院缺血性卒中患者和 928855 例社区发病缺血性卒中患者的患者特征、合并症、药物使用、医疗质量指标和结局。
结果
住院卒中患者具有更多的血栓栓塞风险因素，包括心房颤动、人工心脏瓣膜、颈动脉狭窄和心力衰竭（P<0.0001），且卒中严重程度更重（中位数国立卫生研究院卒中量表评分 9.0 分 vs 4.0 分；P<0.0001）。根据 GWTG-Stroke 达标指标，住院卒中患者实现无缺陷护理的比例更低（60.8% vs 82.0%；P<0.0001）。在校正患者和医院特征后，住院卒中患者出院回家的可能性更低（校正比值比 0.37；95%置信区间 [0.35-0.39]），或出院时独立行走的可能性更低（校正比值比 0.42；95%置信区间 [0.39-0.45]）。住院卒中患者的院内死亡率更高（校正比值比 2.72；95%置信区间 [2.57-2.88]）。
结论
与社区发病缺血性卒中相比，住院卒中患者的卒中更严重，接受的基于流程的质量指标的依从性更低，结局更差。这些发现表明，针对住院卒中患者进行有针对性的质量改进工作具有重要意义。
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