美国养老院居民的抗凝药物使用情况及其与治疗相关的居民、养老院和县特征的地域差异。
Geographic Variation in Anticoagulant Use and Resident, Nursing Home, and County Characteristics Associated With Treatment Among US Nursing Home Residents.
机构信息
Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
出版信息
J Am Med Dir Assoc. 2021 Jan;22(1):164-172.e9. doi: 10.1016/j.jamda.2020.10.001.
OBJECTIVES
To quantify geographic variation in anticoagulant use and explore what resident, nursing home, and county characteristics were associated with anticoagulant use in a clinically complex population.
DESIGN
A repeated cross-sectional design was used to estimate current oral anticoagulant use on December 31, 2014, 2015, and 2016.
SETTING AND PARTICIPANTS
Secondary data for United States nursing home residents during the period 2014-2016 were drawn from the Minimum Data Set 3.0 and Medicare Parts A and D. Nursing home residents (≥65 years) with a diagnosis of atrial fibrillation and ≥6 months of Medicare fee-for-service enrollment were eligible for inclusion. Residents in a coma or on hospice were excluded.
METHODS
Multilevel logistic models evaluated the extent to which variation in anticoagulant use between counties could be explained by resident, nursing home, and county characteristics and state of residence. Proportional changes in cluster variation (PCVs), intraclass correlation coefficients (ICCs), and adjusted odds ratios (aORs) were estimated.
RESULTS
Among 86,736 nursing home residents from 11,860 nursing homes and 1694 counties, 45% used oral anticoagulants. The odds of oral anticoagulant use were 18% higher in 2016 than 2014 (aOR: 1.18; 95% confidence interval: 1.14-1.22). Most states had counties in the highest (51.3-58.9%) and lowest (31.1%-41.4%) deciles of anticoagulant use. Compared with the null model, adjustment for resident characteristics explained one-third of the variation between counties (PCV: 34.8%). The full model explained 65.5% of between-county variation. Within-county correlation was a small proportion (ICC < 2.2%) of total variation.
CONCLUSIONS AND IMPLICATIONS
In this older adult population at high risk for ischemic stroke, less than half of the residents received treatment with anticoagulants. Variation in treatment across counties was partially attributable to the characteristics of residents, nursing homes, and counties. Comparative evidence and refinement of predictive algorithms specific to the nursing home setting may be warranted.
目的
量化抗凝治疗的地域差异，并探讨哪些居民、养老院和县级特征与临床复杂人群中抗凝治疗的使用有关。
设计
采用重复横断面设计，估计 2014 年 12 月 31 日、2015 年和 2016 年目前口服抗凝剂的使用情况。
地点和参与者
这项研究的数据来自 2014 年至 2016 年期间美国养老院居民的 3.0 版最低数据集和医疗保险 A 部分和 D 部分。有房颤诊断且 Medicare 收费服务登记≥6 个月的≥65 岁养老院居民有资格入选。处于昏迷或临终关怀状态的居民被排除在外。
方法
多水平逻辑模型评估了县与县之间抗凝治疗使用的差异在多大程度上可以用居民、养老院和县级特征以及居住州来解释。估计比例变化聚类变异（PCV）、组内相关系数（ICC）和调整后的优势比（aOR）。
结果
在来自 11860 家养老院和 1694 个县的 86736 名养老院居民中，有 45%使用了口服抗凝剂。与 2014 年相比，2016 年使用口服抗凝剂的可能性高 18%（aOR：1.18；95%置信区间：1.14-1.22）。大多数州的县都处于抗凝治疗使用的最高（51.3%-58.9%）和最低（31.1%-41.4%）十分位数。与空模型相比，居民特征的调整解释了县之间三分之一的变异（PCV：34.8%）。全模型解释了县间变异的 65.5%。县内相关性是总变异的一小部分（ICC<2.2%）。
结论和意义
在这个有很高缺血性中风风险的老年人群体中，不到一半的居民接受了抗凝治疗。县与县之间治疗的差异部分归因于居民、养老院和县级特征。可能需要针对养老院环境制定比较证据和改进预测算法。
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