Department of Cardiology, Peking University First Hospital, Beijing, China.
Department of Cardiology, Shanghai Chest Hospital, Shanghai, China.
BMJ Qual Saf. 2021 Nov;30(11):867-875. doi: 10.1136/bmjqs-2020-011491. Epub 2020 Dec 22.
Large-scale real-world data to evaluate the impact of chest pain centre (CPC) accreditation on acute coronary syndrome (ACS) emergency care in heavy-burden developing countries like China are rare.
This study is a retrospective study based on data from the Hospital Quality Monitoring System (HQMS) database. This study included emergency patients admitted with ACS to hospitals that uploaded clinical data continuously to the database from 2013 to 2016. Propensity score matching was used to compare hospitals with and without CPC accreditation during this period. A longitudinal self-contrast comparison design with mixed-effects models was used to compare management of ACS before and after accreditation.
A total of 798 008 patients with ACS from 746 hospitals were included in the analysis. After matching admission date, hospital levels and types and adjusting for possible covariates, patients with ACS admitted to accredited CPCs had lower in-hospital mortality (OR=0.70, 95% CI 0.53 to 0.93), shorter length of stay (LOS; adjusted multiplicative effect=0.89, 95% CI 0.84 to 0.94) and more percutaneous coronary intervention (PCI) procedures (OR=3.53, 95% CI 2.20 to 5.66) than patients admitted in hospitals without applying for CPC accreditation. Furthermore, when compared with the 'before accreditation' group only in accredited CPCs, the in-hospital mortality and LOS decreased and the usage of PCI were increased in both 'accreditation' (for in-hospital mortality: OR=0.86, 95% CI 0.79 to 0.93; for LOS: 0.94, 95% CI 0.93 to 0.95; for PCI: OR=1.22, 95% CI 1.18 to 1.26) and 'after accreditation' groups (for in-hospital mortality: OR=0.90, 95% CI 0.84 to 0.97; for LOS: 0.89, 95% CI 0.89 to 0.90; for PCI: OR=1.36, 95% CI 1.33 to 1.39). The significant benefits of decreased in-hospital mortality, reduced LOS and increased PCI usage were also observed for patients with acute myocardial infarction.
CPC accreditation is associated with better management and in-hospital clinical outcomes of patients with ACS. CPC establishment and accreditation should be promoted and implemented in countries with high levels of ACS.
在中国等医疗负担沉重的发展中国家，很少有大规模的真实世界数据来评估胸痛中心（CPC）认证对急性冠状动脉综合征（ACS）急救护理的影响。
本研究基于医院质量监测系统（HQMS）数据库中的数据，是一项回顾性研究。该研究纳入了 2013 年至 2016 年期间连续向数据库上传临床数据的医院收治的 ACS 急诊患者。在此期间，采用倾向评分匹配比较有和没有 CPC 认证的医院。采用混合效应模型的纵向自身对照设计比较认证前后 ACS 的管理情况。
共纳入了 798008 例来自 746 家医院的 ACS 患者。匹配入院日期、医院级别和类型，并调整了可能的混杂因素后，与未申请 CPC 认证的患者相比，接受 CPC 认证的 ACS 患者院内死亡率（比值比[OR]=0.70，95%置信区间[CI]0.53 至 0.93）更低、住院时间（调整后的乘法效应=0.89，95%CI 0.84 至 0.94）更短，接受经皮冠状动脉介入治疗（PCI）的比例（OR=3.53，95%CI 2.20 至 5.66）更高。此外，与仅在获得 CPC 认证的中心的“认证前”组相比，“认证”组（院内死亡率：OR=0.86，95%CI 0.79 至 0.93；住院时间：0.94，95%CI 0.93 至 0.95；PCI：OR=1.22，95%CI 1.18 至 1.26）和“认证后”组（院内死亡率：OR=0.90，95%CI 0.84 至 0.97；住院时间：0.89，95%CI 0.89 至 0.90；PCI：OR=1.36，95%CI 1.33 至 1.39）的院内死亡率、住院时间降低和 PCI 使用增加的情况更为显著。对于急性心肌梗死患者，也观察到了院内死亡率降低、住院时间缩短和 PCI 使用增加的显著获益。
CPC 认证与 ACS 患者管理和院内临床结局的改善相关。应在 ACS 发生率较高的国家推广和实施 CPC 建立和认证。
