急性冠状动脉综合征患者的临床治理。

Clinical governance of patients with acute coronary syndromes.

机构信息

Department of Molecular Medicine, University of Pavia, Pavia 27100, Italy.

Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.

出版信息

Eur Heart J Acute Cardiovasc Care. 2022 Nov 30;11(11):797-805. doi: 10.1093/ehjacc/zuac106.

AIMS

Using the principles of clinical governance, a patient-centred approach intended to promote holistic quality improvement, we designed a prospective, multicentre study in patients with acute coronary syndrome (ACS). We aimed to verify and quantify consecutive inclusion and describe relative and absolute effects of indicators of quality for diagnosis and therapy.

METHODS AND RESULTS

Administrative codes for invasive coronary angiography and acute myocardial infarction were used to estimate the ACS universe. The ratio between the number of patients included and the estimated ACS universe was the consecutive index. Co-primary quality indicators were timely reperfusion in patients admitted with ST-elevation ACS and optimal medical therapy at discharge. Cox-proportional hazard models for 1-year death with admission and discharge-specific covariates quantified relative risk reductions and adjusted number needed to treat (NNT) absolute risk reductions. Hospital codes tested had a 99.5% sensitivity to identify ACS universe. We estimated that 7344 (95% CI: 6852-7867) ACS patients were admitted and 5107 were enrolled-i.e. a consecutive index of 69.6% (95% CI 64.9-74.5%), which varied from 30.7 to 79.2% across sites. Timely reperfusion was achieved in 22.4% (95% CI: 20.7-24.1%) of patients, was associated with an adjusted hazard ratio (HR) for 1-year death of 0.60 (95% CI: 0.40-0.89) and an adjusted NNT of 65 (95% CI: 44-250). Corresponding values for optimal medical therapy were 70.1% (95% CI: 68.7-71.4%), HR of 0.50 (95% CI: 0.38-0.66), and NNT of 98 (95% CI: 79-145).

CONCLUSION

A comprehensive approach to quality for patients with ACS may promote equitable access of care and inform implementation of health care delivery.

REGISTRATION

ClinicalTrials.Gov ID NCT04255537.

目的

我们采用以患者为中心的临床治理原则，旨在促进整体质量改进，针对急性冠脉综合征（ACS）患者设计了一项前瞻性、多中心研究。我们旨在验证并量化连续纳入患者的情况，并描述诊断和治疗质量指标的相对和绝对效果。

方法和结果

采用经皮冠状动脉造影和急性心肌梗死的管理代码来估计 ACS 人群。纳入患者数量与估计的 ACS 人群的比例为连续指标。主要质量指标为 ST 段抬高型 ACS 患者入院时及时再灌注和出院时最佳药物治疗。采用 Cox 比例风险模型，对入院和出院时特定协变量的 1 年死亡进行量化，计算相对风险降低和调整后的需要治疗人数（NNT）绝对风险降低。测试的医院代码对识别 ACS 人群具有 99.5%的敏感性。我们估计有 7344 例（95%CI：6852-7867）ACS 患者入院，5107 例患者入组，即连续指标为 69.6%（95%CI：64.9-74.5%），各入组中心的连续指标在 30.7%至 79.2%之间不等。22.4%（95%CI：20.7-24.1%）的患者实现了及时再灌注，调整后的 1 年死亡风险比（HR）为 0.60（95%CI：0.40-0.89），调整后的 NNT 为 65（95%CI：44-250）。最佳药物治疗的相应值为 70.1%（95%CI：68.7-71.4%），HR 为 0.50（95%CI：0.38-0.66），NNT 为 98（95%CI：79-145）。