心力衰竭门诊患者不同医疗实践中的健康状况差异：来自CHAMP-HF（改变心力衰竭患者管理）注册研究的见解
Health Status Variation Across Practices in Outpatients With Heart Failure: Insights From the CHAMP-HF (Change the Management of Patients With Heart Failure) Registry.
作者信息
Khariton Yevgeniy, Hernandez Adrian F, Fonarow Gregg C, Sharma Puza P, Duffy Carol I, Thomas Laine, Mi Xiaojuan, Albert Nancy M, Butler Javed, McCague Kevin, Nassif Michael E, Williams Fredonia B, DeVore Adam, Patterson J Herbert, Spertus John A
机构信息
Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.).
出版信息
Circ Cardiovasc Qual Outcomes. 2018 Apr;11(4):e004668. doi: 10.1161/CIRCOUTCOMES.118.004668.
BACKGROUND
Although a key treatment goal for patients with heart failure with reduced ejection fraction is to optimize their health status (their symptoms, function, and quality of life), the variability across outpatient practices in achieving this goal is unknown.
METHODS AND RESULTS
In the CHAMP-HF (Change the Management of Patients With Heart Failure) registry, associations between baseline practice characteristics and Kansas City Cardiomyopathy Questionnaire (KCCQ) Overall Summary (OS) and Symptom Frequency (SF) scores were assessed in 3494 patients across 140 US practices using hierarchical regression after accounting for 23 patient and 11 treatment characteristics. We then calculated an adjusted median odds ratio to quantify the average difference in likelihood that a patient would have excellent (KCCQ-OS, ≥75) health status or minimal (monthly or fewer) symptoms (KCCQ-SF, ≥75) when treated at one practice versus another, at random. The mean (±SD) KCCQ-OS and KCCQ-SF were 64.2±24 and 68.9±25.6, with 40% (n=1380) and 50% (n=1760) having KCCQ scores ≥75, respectively. The adjusted median odds ratio across practices, for KCCQ-OS ≥75, was 1.70 (95% confidence interval, 1.54-1.99; <0.001) indicating a median 70% higher odds of a patient having good-to-excellent health status when treated at one random practice versus another. In regard to KCCQ-SF, the adjusted median odds ratio for KCCQ-SF ≥75 was 1.54 (95% confidence interval, 1.41-1.76; =0.001).
CONCLUSIONS
In a large, contemporary registry of outpatients with chronic heart failure with reduced ejection fraction, we observed significant practice-level variability in patients' health status. Quantifying patients' health status as a measure of quality should be explored as a foundation for improving care.
CLINICAL TRIAL REGISTRATION
URL: https://www.centerwatch.com. Unique identifier: TX144901.
背景
尽管射血分数降低的心力衰竭患者的一个关键治疗目标是优化其健康状况（症状、功能和生活质量），但在实现这一目标的门诊实践中的变异性尚不清楚。
方法与结果
在CHAMP-HF（改变心力衰竭患者的管理）注册研究中，在考虑了23项患者特征和11项治疗特征后，使用分层回归对美国140家医疗机构的3494例患者的基线实践特征与堪萨斯城心肌病问卷（KCCQ）总体总结（OS）和症状频率（SF）评分之间的关联进行了评估。然后，我们计算了调整后的中位数优势比，以量化患者在随机选择的一家医疗机构接受治疗与另一家相比，获得极佳（KCCQ-OS，≥75）健康状况或极少（每月或更少）症状（KCCQ-SF，≥75）的可能性的平均差异。KCCQ-OS和KCCQ-SF的均值（±标准差）分别为64.2±24和68.9±25.6，分别有40%（n = 1380）和50%（n = 1760）的患者KCCQ评分≥75。各医疗机构间KCCQ-OS≥75的调整后中位数优势比为1.70（95%置信区间，1.54 - 1.99；<0.001），表明患者在随机选择的一家医疗机构接受治疗与另一家相比，获得良好至极佳健康状况的中位数优势高70%。关于KCCQ-SF，KCCQ-SF≥75的调整后中位数优势比为1.54（95%置信区间，1.41 - 1.76；=0.001）。
结论
在一个大型的当代射血分数降低的慢性心力衰竭门诊患者注册研究中，我们观察到患者健康状况在医疗机构层面存在显著变异性。应探索将量化患者健康状况作为质量衡量指标，作为改善护理的基础。
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