Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora.
Circ Heart Fail. 2014 Mar 1;7(2):251-60. doi: 10.1161/CIRCHEARTFAILURE.113.000761. Epub 2014 Jan 31.
Prior claims analyses suggest that the use of intravenous inotropic therapy for patients hospitalized with heart failure varies substantially by hospital. Whether differences in the clinical characteristics of the patients explain observed differences in the use of inotropic therapy is not known.
We sought to characterize institutional variation in inotrope use among patients hospitalized with heart failure before and after accounting for clinical factors of patients. Hierarchical generalized linear regression models estimated risk-standardized hospital-level rates of inotrope use within 209 hospitals participating in Get With The Guidelines-Heart Failure (GWTG-HF) registry between 2005 and 2011. The association between risk-standardized rates of inotrope use and clinical outcomes was determined. Overall, an inotropic agent was administered in 7691 of 126 564 (6.1%) heart failure hospitalizations: dobutamine 43%, dopamine 24%, milrinone 17%, or a combination 16%. Patterns of inotrope use were stable during the 7-year study period. Use of inotropes varied significantly between hospitals even after accounting for patient and hospital characteristics (median risk-standardized hospital rate, 5.9%; interquartile range, 3.7%-8.6%; range, 1.3%-32.9%). After adjusting for case-mix and hospital structural differences, model intraclass correlation indicated that 21% of the observed variation in inotrope use was potentially attributable to random hospital effects (ie, institutional preferences). Hospitals with higher risk-standardized inotrope use had modestly longer risk-standardized length of stay (P=0.005) but had no difference in risk-standardized inpatient mortality (P=0.12).
Use of intravenous inotropic agents during hospitalization for heart failure varies significantly among US hospitals even after accounting for patient and hospital factors.
先前的索赔分析表明，心力衰竭住院患者静脉内正性肌力治疗的使用在医院之间存在很大差异。患者临床特征的差异是否可以解释观察到的正性肌力治疗使用的差异尚不清楚。
我们试图在考虑心力衰竭住院患者的临床因素之前和之后，描述医院内正性肌力药物使用的机构差异。在 2005 年至 2011 年期间，在参与 Get With The Guidelines-Heart Failure（GWTG-HF）登记处的 209 家医院中，使用分层广义线性回归模型估计了风险标准化的医院内正性肌力药物使用率。确定了风险标准化的正性肌力药物使用率与临床结果之间的关联。总体而言，在 126564 例心力衰竭住院患者中，有 7691 例（6.1%）使用了正性肌力药物：多巴酚丁胺 43%，多巴胺 24%，米力农 17%或两者的组合 16%。在 7 年的研究期间，正性肌力药物的使用模式保持稳定。即使在考虑患者和医院特征后，医院之间的正性肌力药物使用差异也很大（中位数风险标准化医院率为 5.9%；四分位距为 3.7%-8.6%；范围为 1.3%-32.9%）。在校正病例组合和医院结构差异后，模型组内相关系数表明，观察到的正性肌力药物使用差异中有 21%可能归因于随机医院效应（即机构偏好）。风险标准化的正性肌力药物使用率较高的医院风险标准化的住院时间略长（P=0.005），但风险标准化的住院死亡率没有差异（P=0.12）。
即使在考虑患者和医院因素后，美国医院心力衰竭住院患者静脉内正性肌力药物的使用差异仍然很大。
