与因心力衰竭入院患者的医院容量、护理过程和结局之间的关联：来自 Get With The Guidelines-Heart Failure 的见解。
Association Between Hospital Volume, Processes of Care, and Outcomes in Patients Admitted With Heart Failure: Insights From Get With The Guidelines-Heart Failure.
机构信息
Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.J.K.).
UCLA Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, Los Angeles, CA (G.C.F.).
出版信息
Circulation. 2018 Apr 17;137(16):1661-1670. doi: 10.1161/CIRCULATIONAHA.117.028077. Epub 2018 Jan 29.
BACKGROUND
Hospital volume is frequently used as a structural metric for assessing quality of care, but its utility in patients admitted with acute heart failure (HF) is not well characterized. Accordingly, we sought to determine the relationship between admission volume, process-of-care metrics, and short- and long-term outcomes in patients admitted with acute HF.
METHODS
Patients enrolled in the Get With The Guidelines-HF registry with linked Medicare inpatient data at 342 hospitals were assessed. Volume was assessed both as a continuous variable, and quartiles based on the admitting hospital annual HF case volume, as well: 5 to 38 (quartile 1), 39 to 77 (quartile 2), 78 to 122 (quartile 3), 123 to 457 (quartile 4). The main outcome measures were (1) process measures at discharge (achievement of HF achievement, quality, reporting, and composite metrics); (2) 30-day mortality and hospital readmission; and (3) 6-month mortality and hospital readmission. Adjusted logistic and Cox proportional hazards models were used to study these associations with hospital volume.
RESULTS
A total of 125 595 patients with HF were included. Patients admitted to high-volume hospitals had a higher burden of comorbidities. On multivariable modeling, lower-volume hospitals were significantly less likely to be adherent to HF process measures than higher-volume hospitals. Higher hospital volume was not associated with a difference in in-hospital (odds ratio, 0.99; 95% confidence interval [CI], 0.94-1.05; =0.78) or 30-day mortality (hazard ratio, 0.99; 95% CI, 0.97-1.01; =0.26), or 30-day readmissions (hazard ratio, 0.99; 95% CI, 0.97-1.00; =0.10). There was a weak association of higher volumes with lower 6-month mortality (hazard ratio, 0.98; 95% CI, 0.97-0.99; =0.001) and lower 6-month all-cause readmissions (hazard ratio, 0.98; 95%, CI 0.97-1.00; =0.025).
CONCLUSIONS
Our analysis of a large contemporary prospective national quality improvement registry of older patients with HF indicates that hospital volume as a structural metric correlates with process measures, but not with 30-day outcomes, and only marginally with outcomes up to 6 months of follow-up. Hospital profiling should focus on participation in systems of care, adherence to process metrics, and risk-standardized outcomes rather than on hospital volume itself.
背景
医院容量常被用作评估医疗质量的结构指标，但在急性心力衰竭（HF）患者中的应用尚未得到充分描述。因此，我们旨在确定急性 HF 患者入院容量、治疗过程指标与短期和长期结局之间的关系。
方法
在 342 家医院进行的 Get With The Guidelines-HF 注册研究中，纳入了有医疗保险住院数据的患者。容量评估采用连续变量和基于入院医院每年 HF 病例量的四分位数：5 至 38（四分位数 1），39 至 77（四分位数 2），78 至 122（四分位数 3），123 至 457（四分位数 4）。主要结局指标为（1）出院时的治疗过程指标（HF 达标、质量、报告和综合指标的达标情况）；（2）30 天死亡率和再入院率；（3）6 个月死亡率和再入院率。使用校正的逻辑和 Cox 比例风险模型研究了这些与医院容量的关联。
结果
共纳入了 125595 例 HF 患者。容量较高的医院患者合并症负担更重。多变量模型分析显示，低容量医院的 HF 治疗过程指标达标率明显低于高容量医院。高医院容量与院内（比值比，0.99；95%置信区间[CI]，0.94-1.05；=0.78）或 30 天死亡率（风险比，0.99；95%CI，0.97-1.01；=0.26）或 30 天再入院率（风险比，0.99；95%CI，0.97-1.00；=0.10）均无差异。高容量与较低的 6 个月死亡率（风险比，0.98；95%CI，0.97-0.99；=0.001）和较低的 6 个月全因再入院率（风险比，0.98；95%CI，0.97-1.00；=0.025）有较弱的关联。
结论
我们对老年 HF 患者的大型当代前瞻性国家质量改进注册研究的分析表明，作为结构指标的医院容量与治疗过程指标相关，但与 30 天结局无关，仅与 6 个月随访的结局略有相关。医院概况应侧重于参与医疗保健系统、治疗过程指标的达标情况以及风险标准化的结局，而不是医院容量本身。
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