Downing Nicholas S, Wang Yongfei, Dharmarajan Kumar, Nuti Sudhakar V, Murugiah Karthik, Du Xue, Zheng Xin, Li Xi, Li Jing, Masoudi Frederick A, Spertus John A, Jiang Lixin, Krumholz Harlan M
Department of Medicine, Brigham and Women's Hospital, Boston, MA.
Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT.
J Am Heart Assoc. 2017 Jun 23;6(6):e005040. doi: 10.1161/JAHA.116.005040.
China has gaps in the quality of care provided to patients with ST-elevation myocardial infarction, but little is known about how quality varies between hospitals.
Using nationally representative data from the China PEACE-Retrospective AMI Study, we characterized the quality of care for ST-elevation myocardial infarction at the hospital level and examined variation between hospitals. Two summary measures were used to describe the overall quality of care at each hospital and to characterize variations in quality between hospitals in 2001, 2006, and 2011. The composite rate measured the proportion of opportunities a hospital had to deliver 6 guideline-recommended treatments for ST-elevation myocardial infarction that were successfully met, while the defect-free rate measured the proportion of patients at each hospital receiving all guideline-recommended treatments for which they were eligible. Risk-standardized mortality rates were calculated. Our analysis included 12 108 patients treated for ST-elevation myocardial infarction at 162 hospitals. The median composite rate increased from 56.8% (interquartile range [IQR], 45.9-72.0) in 2001 to 80.5% (IQR, 74.7-84.8) in 2011; however, substantial variation remained in 2011 with defect-free rates ranging from 0.0% to 76.9%. The median risk-standardized mortality rate increased from 9.9% (IQR, 9.1-11.7) in 2001 to 12.6% (IQR, 10.9-14.6) in 2006 before falling to 10.4% (IQR, 9.1-12.4) in 2011.
Higher rates of guideline-recommended care and a decline in variation between hospitals are indicative of an improvement in quality. Although some variation persisted in 2011, very top-performing hospitals missed few opportunities to provide guideline-recommended care. Quality improvement initiatives should focus on eliminating residual variation as well as measuring and improving outcomes.
URL: https://www.clinicaltrials.gov. Unique identifier: NCT01624883.
中国在为ST段抬高型心肌梗死患者提供的医疗服务质量方面存在差距，但对于医院之间质量如何存在差异却知之甚少。
利用中国心脏重症注册登记研究（China PEACE-Retrospective AMI Study）具有全国代表性的数据，我们在医院层面描述了ST段抬高型心肌梗死的医疗服务质量，并研究了医院之间的差异。采用两种综合指标来描述每家医院的整体医疗服务质量，并刻画2001年、2006年和2011年医院之间质量的差异。综合达标率衡量一家医院成功实施6项ST段抬高型心肌梗死指南推荐治疗措施的机会比例，而无缺陷率衡量每家医院接受所有符合条件的指南推荐治疗措施的患者比例。计算了风险标准化死亡率。我们的分析纳入了162家医院的12108例ST段抬高型心肌梗死患者。综合达标率中位数从2001年的56.8%（四分位间距[IQR]，45.9-72.0）升至2011年的80.5%（IQR，74.7-84.8）；然而，2011年仍存在显著差异，无缺陷率范围为0.0%至76.9%。风险标准化死亡率中位数从2001年的9.9%（IQR，9.1-11.7）升至2006年的12.6%（IQR，10.9-14.6），随后在2011年降至10.4%（IQR，9.1-12.4）。
更高的指南推荐治疗比例以及医院间差异的下降表明质量有所改善。尽管2011年仍存在一些差异，但表现非常出色的医院很少错过提供指南推荐治疗的机会。质量改进举措应侧重于消除残余差异以及衡量和改善治疗结果。
