Saint Luke's Mid America Heart Institute, Kansas City, MO (A.T.T., S.V.A., P.G.J., J.A.S.).
University of Missouri-Kansas City (A.T.T., S.V.A., P.G.J., J.A.S.).
Circ Cardiovasc Qual Outcomes. 2021 Oct;14(10):e008072. doi: 10.1161/CIRCOUTCOMES.121.008072. Epub 2021 Oct 7.
Health status outcomes are increasingly being promoted as measures of health care quality, given their importance to patients. In heart failure (HF), an American College of Cardiology/American Heart Association Task Force proposed using the proportion of patients with preserved health status as a quality measure but not as a performance measure because risk adjustment methods were not available.
We built risk adjustment models for alive with preserved health status and for preserved health status alone in a prospective registry of outpatients with HF with reduced ejection fraction across 146 US centers between December 2015 and October 2017. Preserved health status was defined as not having a ≥5-point decrease in the Kansas City Cardiomyopathy Questionnaire Overall Summary score at 1 year. Using only patient-level characteristics, hierarchical multivariable logistic regression models were developed for 1-year outcomes and validated using data from 1 to 2 years. We examined model calibration, discrimination, and variability in sites' unadjusted and adjusted rates.
Among 3932 participants (median age [interquartile range] 68 years [59-75], 29.7% female, 75.4% White), 2703 (68.7%) were alive with preserved health status, 902 (22.9%) were alive without preserved health status, and 327 (8.3%) had died by 1 year. The final risk adjustment model for alive with preserved health status included baseline Kansas City Cardiomyopathy Questionnaire Overall Summary, age, race, employment status, annual income, body mass index, depression, atrial fibrillation, renal function, number of hospitalizations in the past 1 year, and duration of HF (optimism-corrected C statistic=0.62 with excellent calibration). Similar results were observed when deaths were ignored. The risk standardized proportion of patients alive with preserved health status across the 146 sites ranged from 62% at the 10th percentile to 75% at the 90th percentile. Variability across sites was modest and changed minimally with risk adjustment.
Through leveraging data from a large, outpatient, observational registry, we identified key factors to risk adjust sites' proportions of patients with preserved health status. These data lay the foundation for building quality measures that quantify treatment outcomes from patients' perspectives.
鉴于健康状况对患者的重要性，健康状况结果越来越多地被作为医疗保健质量的衡量标准。在心力衰竭（HF）中，美国心脏病学会/美国心脏协会工作组提出使用具有健康状况保存的患者比例作为质量衡量标准，但不作为绩效衡量标准，因为尚无法进行风险调整。
我们构建了存活且具有健康状况保存和仅具有健康状况保存的风险调整模型，模型数据来源于 2015 年 12 月至 2017 年 10 月期间，146 个美国中心的射血分数降低的心力衰竭门诊患者前瞻性登记处。健康状况保存定义为在 1 年内 Kansas City 心肌病问卷总评分无≥5 分的下降。仅使用患者水平的特征，采用分层多变量逻辑回归模型对 1 年的结果进行了开发，并使用 1 至 2 年的数据进行了验证。我们检查了模型校准、区分度以及各站点未调整和调整后比率的变异性。
在 3932 名参与者（中位数年龄[四分位数范围]68 岁[59-75]，29.7%为女性，75.4%为白人）中，2703 名（68.7%）存活且具有健康状况保存，902 名（22.9%）存活但无健康状况保存，327 名（8.3%）在 1 年内死亡。存活且具有健康状况保存的最终风险调整模型包括基线 Kansas City 心肌病问卷总评分、年龄、种族、就业状况、年收入、体重指数、抑郁、心房颤动、肾功能、过去 1 年的住院次数和心力衰竭持续时间（校正乐观偏差后的 C 统计量=0.62，具有极好的校准）。当忽略死亡时，也观察到类似的结果。在 146 个站点中，具有健康状况保存的患者存活比例的风险标准化比例范围从第 10 个百分位数的 62%到第 90 个百分位数的 75%。各站点间的变异性较小，且风险调整后变化不大。
通过利用来自大型门诊观察性登记处的数据，我们确定了对各站点具有健康状况保存的患者比例进行风险调整的关键因素。这些数据为构建从患者角度量化治疗结果的质量衡量标准奠定了基础。
