为退伍军人事务部的静脉曲张患者提供的护理质量。

The quality of care provided to patients with varices in the department of Veterans Affairs.

机构信息

Center for Outcomes Research, Saint Louis University, Saint Louis, Missouri, USA.

Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.

出版信息

Am J Gastroenterol. 2014 Jul;109(7):934-40. doi: 10.1038/ajg.2013.487.

DOI:10.1038/ajg.2013.487

PMID:24989087

Abstract

OBJECTIVES

Practice guidelines define the criteria and standards of care in patients with cirrhosis and varices. However, the extent to which the patients receive recommended care is largely unknown. We evaluated the quality of varices related care and factors associated with receipt of such care.

METHODS

We conducted a retrospective cohort study of 550 patients with cirrhosis who sought care at three VA facilities between 2000 and 2007. Using administrative and clinical data, we assessed quality of varices care as measured by eight explicit Delphi panel-derived quality indicators. We also conducted a structured implicit review of patients' medical records to explore the role of patients' refusal, receipt of care outside the VA, or justifiable exclusions to certain care processes as explanations for non-adherence to the quality indicators.

RESULTS

Quality scores (max. 100%) varied across individual indicators, ranging from 24.3% for upper endoscopy for varices screening to 72.4% for secondary prophylaxis for variceal bleeding. Justifiable exclusions to indicated care documented in charts were common for primary prophylaxis in patients with varices; receipt of endoscopy; and endoscopic treatment in patients with active bleeding. In contrast, significant shortfalls remained in the receipt of screening endoscopy, use of beta-blockers (in the absence of varices), and use of somatostatin analogs, antibiotics, and secondary prophylaxis in patients with variceal bleeding. Younger patients (<60 vs. >60 year, odds ratio (OR)=1.29, 95% confidence interval (CI) 1.01-1.68), those who saw a gastroenterologist (OR=1.55, 95% CI=1.09-2.21), or those who were seen in the facility with academic affiliation (OR=1.26, 95% CI=1.01-1.58) received higher quality care.

CONCLUSIONS

Health-care quality, measured according to whether patients received recommended varices-related care, was suboptimal in this health-care setting. Care that included gastroenterologists was associated with high quality.

摘要

目的

临床实践指南定义了肝硬化和静脉曲张患者的护理标准和准则。然而，患者接受推荐护理的程度在很大程度上尚不清楚。我们评估了静脉曲张相关护理的质量以及与接受此类护理相关的因素。

方法

我们对 2000 年至 2007 年间在三个退伍军人事务部设施就诊的 550 例肝硬化患者进行了回顾性队列研究。使用行政和临床数据，我们评估了静脉曲张护理质量，其方法是使用八个明确的德尔菲小组制定的质量指标进行评估。我们还对患者的病历进行了结构化的隐性审查，以探讨患者拒绝、在退伍军人事务部以外接受护理或对某些护理过程进行合理排除作为不遵守质量指标的解释的作用。

结果

个别指标的质量评分（最高 100%）各不相同，从静脉曲张筛查的上内窥镜检查的 24.3%到静脉曲张出血的二级预防的 72.4%。在病历中有记录的静脉曲张一级预防、内镜检查和内镜治疗患者中，合理排除了有指征的护理；在有活动出血的患者中，接受内镜检查和β受体阻滞剂（无静脉曲张）以及生长抑素类似物、抗生素和静脉曲张出血二级预防的比例较低。与年龄较大（＞60 岁）的患者相比，年龄较小（＜60 岁）的患者（比值比[OR]=1.29，95%置信区间[CI]1.01-1.68）、看胃肠病学家的患者（OR=1.55，95%CI=1.09-2.21）或在设有学术附属机构的设施就诊的患者（OR=1.26，95%CI=1.01-1.58）接受的护理质量更高。