van Diepen Sean, Bakal Jeffrey A, Lin Meng, Kaul Padma, McAlister Finlay A, Ezekowitz Justin A
Divisions of Critical Care and Cardiology, University of Alberta, Edmonton, Alberta, Canada (S.D.) Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada (S.D., J.A.B., M.L., P.K., F.A.M.A., J.A.E.).
Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada (S.D., J.A.B., M.L., P.K., F.A.M.A., J.A.E.).
J Am Heart Assoc. 2015 Feb 27;4(3):e001708. doi: 10.1161/JAHA.114.001708.
Little is known about cross-hospital differences in critical care units admission rates and related resource utilization and outcomes among patients hospitalized with acute coronary syndromes (ACS) or heart failure (HF).
Using a population-based sample of 16,078 patients admitted to a critical care unit with a primary diagnosis of ACS (n=14,610) or HF (n=1467) between April 1, 2003 and March 31, 2013 in Alberta, Canada, we stratified hospitals into high (>250), medium (200 to 250), or low (<200) volume based on their annual volume of all ACS and HF hospitalization. The percentage of hospitalized patients admitted to critical care units varied across low, medium, and high-volume hospitals for both ACS and HF as follows: 77.9%, 81.3%, and 76.3% (P<0.001), and 18.0%, 16.3%, and 13.0% (P<0.001), respectively. Compared to low-volume units, critical care patients with ACS and HF admitted to high-volume hospitals had shorter mean critical care stays (56.6 versus 95.6 hours, P<0.001), more critical care procedures (1.9 versus 1.2 per patient, <0.001), and higher resource-intensive weighting (2.8 versus 1.5, P<0.001). No differences in in-hospital mortality (5.5% versus 6.2%, adjusted odds ratio 0.93; 95% CI, 0.61 to 1.41) were observed between high- and low-volume hospitals; however, 30-day cardiovascular readmissions (4.6% versus 6.8%, odds ratio 0.77; 95% CI, 0.60 to 0.99) and cardiovascular emergency-room visits (6.6% versus 9.5%, odds ratio 0.80; 95% CI, 0.69 to 0.94) were lower in high-volume compared to low-volume hospitals. Outcomes stratified by ACS or HF admission diagnosis were similar.
Cardiac patients hospitalized in low-volume hospitals were more frequently admitted to critical care units and had longer hospitals stays despite lower resource-intensive weighting. These findings may provide opportunities to standardize critical care utilization for ACS and HF patients across high- and low-volume hospitals.
对于急性冠状动脉综合征（ACS）或心力衰竭（HF）住院患者，重症监护病房（ICU）收治率、相关资源利用情况及预后在不同医院之间的差异鲜为人知。
利用基于人群的样本，选取了2003年4月1日至2013年3月31日期间在加拿大艾伯塔省因主要诊断为ACS（n = 14,610）或HF（n = 1467）而入住ICU的16,078例患者，我们根据所有ACS和HF住院患者的年收治量，将医院分为高收治量（>250例）、中收治量（200至250例）或低收治量（<200例）。对于ACS和HF患者，入住ICU的住院患者百分比在低、中、高收治量医院之间有所不同，具体如下：77.9%、81.3%和76.3%（P<0.001），以及18.0%、16.3%和13.0%（P<0.001）。与低收治量医院相比，入住高收治量医院的ACS和HF重症监护患者的平均重症监护住院时间更短（56.6小时对95.6小时，P<0.001），接受的重症监护程序更多（每位患者1.9次对1.2次，P<0.001），且资源密集权重更高（2.8对1.5，P<0.001）。高、低收治量医院之间在院内死亡率方面未观察到差异（5.5%对6.2%，调整后的优势比为0.93；95%可信区间，0.61至1.41）；然而，高收治量医院的30天心血管再入院率（4.6%对6.8%，优势比为0.77；95%可信区间，0.60至0.99）和心血管急诊就诊率（6.6%对9.5%，优势比为0.80；95%可信区间，0.69至0.94）低于低收治量医院。按ACS或HF入院诊断分层的结果相似。
尽管资源密集权重较低，但在低收治量医院住院的心脏病患者更频繁地入住重症监护病房，且住院时间更长。这些发现可能为规范高、低收治量医院中ACS和HF患者的重症监护利用提供机会。
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