Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
Oklahoma Foundation for Medical Quality, Oklahoma City.
JAMA Intern Med. 2014 Nov;174(11):1806-14. doi: 10.1001/jamainternmed.2014.4501.
Nearly every US acute care hospital reports publicly on adherence to recommended processes of care for patients hospitalized with pneumonia. However, it remains uncertain how much performance of these process measures has improved over time or whether performance is associated with superior patient outcomes.
To describe trends in processes of care, mortality, and readmission for elderly patients hospitalized for pneumonia and to assess the independent associations between processes and outcomes of care.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study conducted from January 1, 2006, to December 31, 2010, at 4740 US acute care hospitals. The cohort included 1 818 979 cases of pneumonia in elderly (≥65 years), Medicare fee-for-service patients who were eligible for at least 1 of 7 pneumonia inpatient processes of care tracked by the Centers for Medicare & Medicaid Services (CMS).
Annual performance rates for 7 pneumonia processes of care and an all-or-none composite of these measures; and 30-day, all-cause mortality and hospital readmission, adjusted for patient and hospital characteristics.
Adjusted annual performance rates for all 7 CMS processes of care (expressed in percentage points per year) increased significantly from 2006 to 2010, ranging from 1.02 for antibiotic initiation within 6 hours to 5.30 for influenza vaccination (P < .001). All 7 measures were performed in more than 92% of eligible cases in 2010. The all-or-none composite demonstrated the largest adjusted relative increase over time (6.87 percentage points per year; P < .001) and was achieved in 87.4% of cases in 2010. Adjusted annual mortality decreased by 0.09 percentage points per year (P < .001), driven primarily by decreasing mortality in the subgroup not treated in the intensive care unit (ICU) (-0.18 percentage points per year; P < .001). Adjusted annual readmission rates decreased significantly by 0.25 percentage points per year (P < .001). All 7 processes of care were independently associated with reduced 30-day mortality, and 5 were associated with reduced 30-day readmission.
Performance of processes of care for elderly patients hospitalized for pneumonia improved substantially from 2006 to 2010. Adjusted 30-day mortality declined slightly over time primarily owing to improved survival among non-ICU patients, and all individual processes of care were independently associated with reduced mortality.
几乎每家美国急症护理医院都报告了其对因肺炎住院的患者进行建议治疗过程的依从情况。然而，尚不清楚这些过程测量的执行情况随时间推移有多大改善，或者其执行情况是否与更好的患者结果相关联。
描述老年肺炎住院患者的治疗过程、死亡率和再入院情况的变化趋势，并评估这些治疗过程与患者预后之间的独立关联。
设计、设置和参与者：这是一项回顾性队列研究，于 2006 年 1 月 1 日至 2010 年 12 月 31 日在 4740 家美国急症护理医院进行。该队列包括 1818979 例 Medicare 按服务项目付费的老年（≥65 岁）肺炎患者，这些患者符合 7 种肺炎住院治疗过程中的至少 1 种，这 7 种过程由医疗保险和医疗补助服务中心（CMS）跟踪。
每年 7 种肺炎治疗过程的执行率以及这些措施的全部或无复合指标；30 天全因死亡率和医院再入院率，按患者和医院特征进行调整。
从 2006 年到 2010 年，所有 7 项 CMS 治疗过程的调整后年度执行率（以每年百分点表示）显著增加，范围从抗生素起始治疗的 6 小时内提高 1.02 个百分点到流感疫苗接种提高 5.30 个百分点（P <.001）。在 2010 年，所有 7 项措施在超过 92%的合格病例中得到执行。全部或无复合指标在时间上的调整后相对增加幅度最大（每年 6.87 个百分点；P <.001），并在 2010 年达到 87.4%。每年的死亡率调整后下降了 0.09 个百分点（P <.001），主要原因是 ICU 治疗患者的死亡率下降（每年 0.18 个百分点；P <.001）。每年的调整后再入院率显著下降 0.25 个百分点（P <.001）。所有 7 项治疗过程都与降低 30 天死亡率独立相关，5 项治疗过程与降低 30 天再入院率独立相关。
从 2006 年到 2010 年，老年肺炎住院患者的治疗过程执行情况有了显著改善。随着时间的推移，调整后的 30 天死亡率略有下降，主要原因是 ICU 患者的生存率提高，而所有的单个治疗过程都与死亡率的降低独立相关。
