心脏康复参与度在主动脉瓣置换术护理期间的变化。
Variation in Cardiac Rehabilitation Participation During Aortic Valve Replacement Episodes of Care.
机构信息
Department of Internal Medicine, University of California, San Francisco (V.G.).
Michigan Value Collaborative, University of Michigan, Ann Arbor (V.G., J.M.Y., M.P.T.).
出版信息
Circ Cardiovasc Qual Outcomes. 2022 Jul;15(7):e009175. doi: 10.1161/CIRCOUTCOMES.122.009175. Epub 2022 May 13.
BACKGROUND
Despite reported benefit in the setting of aortic valve replacement (AVR), cardiac rehabilitation (CR) utilization remains low, with few studies evaluating hospital and patient-level variation in CR participation. We explored determinants of CR variability during AVR episodes of care: transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR).
METHODS
A cohort of 10 124 AVR episodes of care (TAVR n=5121 from 24 hospitals; SAVR n=5003 from 32 hospitals) were identified from the Michigan Value Collaborative statewide multipayer registry (2015-2019). CR enrollment was defined as the presence of a single professional or facility claim within 90 days of discharge: 93 797, 93 798, G0422, G0423. Annual trends and hospital variation in CR were described for TAVR, SAVR, and all AVR. Multilevel logistic regression was used to estimate effects of predictors and hospital risk-adjusted rates of CR enrollment.
RESULTS
Overall, 4027 (39.8%) patients enrolled in CR, with significant differences by treatment strategy: SAVR=50.9%, TAVR=28.9% (<0.001). CR use after SAVR was significantly higher than after TAVR and increased over time for both modalities (<0.001). There were significant differences in CR enrollment across age, gender, payer, and some comorbidities (<0.05). At the hospital level, CR participation rates for all AVR varied 10-fold (4.8% to 68.7%) and were moderately correlated between SAVR and TAVR (Pearson =0.56, <0.01).
CONCLUSIONS
Substantial variation exists in CR participation during AVR episodes of care across hospitals. However, within-hospital CR participation rates were significantly correlated across treatment strategies. These findings suggest that CR participation is the product of hospital-specific practice patterns. Identifying hospital practices associated with higher CR participation can help assist future quality improvement efforts to increase CR use after AVR.
背景
尽管有报道称主动脉瓣置换术（AVR）有获益，但心脏康复（CR）的利用率仍然较低，很少有研究评估医院和患者层面参与 CR 的差异。我们探讨了 AVR 治疗期间 CR 变异性的决定因素：经导管主动脉瓣置换术（TAVR）和外科主动脉瓣置换术（SAVR）。
方法
从密歇根州价值协作全州多支付方登记处（2015-2019 年）中确定了 10124 例 AVR 治疗期（24 家医院的 TAVR 5121 例；32 家医院的 SAVR 5003 例）。CR 登记定义为出院后 90 天内有单一专业或机构的索赔：93797、93798、G0422、G0423。描述了 TAVR、SAVR 和所有 AVR 的年度趋势和医院变异。使用多水平逻辑回归估计预测因子和医院风险调整的 CR 登记率的影响。
结果
总体而言，4027 例（39.8%）患者登记参加了 CR，两种治疗策略之间存在显著差异：SAVR=50.9%，TAVR=28.9%（<0.001）。SAVR 后 CR 的使用率明显高于 TAVR，并且两种方式的使用率都随着时间的推移而增加（<0.001）。在年龄、性别、支付方和一些合并症方面存在 CR 登记的差异（<0.05）。在医院层面，所有 AVR 的 CR 参与率差异达 10 倍（4.8%至 68.7%），SAVR 和 TAVR 之间存在中度相关性（Pearson=0.56，<0.01）。
结论
在 AVR 治疗期间，医院之间的 CR 参与度存在很大差异。然而，治疗策略之间的院内 CR 参与率存在显著相关性。这些发现表明，CR 参与是医院特定实践模式的产物。确定与更高的 CR 参与率相关的医院实践可以帮助协助未来提高 AVR 后 CR 使用率的质量改进工作。
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