Philbin E F, Lynch L J, Rocco T A, Lindenmuth N W, Ulrich K, McCall M, Jenkins P, Roerden J B
Division of Cardiology, Bassett Healthcare, Cooperstown, NY, USA.
Jt Comm J Qual Improv. 1996 Nov;22(11):721-33. doi: 10.1016/s1070-3241(16)30278-4.
In an ongoing study, a randomized, controlled trial is being conducted on the effects of a collaborative quality improvement program on practice patterns and patient outcomes regarding congestive heart failure (CHF) in community hospitals in upstate New York. CHF is associated with severe morbidity and mortality, with annual rates of death exceeding 50% among patients with the most severe disease.
Phase I of the study was designed to model the processes of care and outcomes, develop valid disease-specific risk adjustment techniques, and target areas for quality improvement (QI) intervention. Beginning April 1, 1995, and ending December 31, 1995, baseline data were collected during hospitalization and for six months postdischarge for all 1,402 consecutive patients assigned diagnosis-related groups (DRGs) 127 and 124. Preliminary analyses revealed high rates of hospital readmission (46%) and postdischarge death (18%), with significant interhospital variation.
Initiatives include educational programs on CHF, feedback of Phase I data to clinicians and administrators, design and implementation of a clinical care pathway, improvement of the emergency department (prehospital) phase of CHF management, and improvement in patient education and discharge planning.
The study suggests that community hospitals, many without extensive experience in clinical investigation, can voluntarily collaborate to design and implement a timely QI initiative that is evidence based, clinically relevant, and scientifically sound. Preliminary results have led to better understanding of the processes of care and determinants of outcome for patients with heart failure. Phase II of the study should yield insights into the providers' response to a locally derived intervention and the effects of such a program on patient outcomes.
在一项正在进行的研究中，针对纽约州北部社区医院充血性心力衰竭（CHF）的实践模式和患者预后，正在开展一项关于协作质量改进计划效果的随机对照试验。CHF与严重的发病率和死亡率相关，在病情最严重的患者中，年死亡率超过50%。
该研究的第一阶段旨在对护理流程和预后进行建模，开发有效的疾病特异性风险调整技术，并确定质量改进（QI）干预的目标领域。从1995年4月1日开始，到1995年12月31日结束，对所有1402例被分配到诊断相关组（DRG）127和124的连续患者，在住院期间和出院后6个月收集基线数据。初步分析显示，医院再入院率（46%）和出院后死亡率（18%）较高，且医院间存在显著差异。
QI举措：举措包括开展关于CHF的教育项目，向临床医生和管理人员反馈第一阶段数据，设计并实施临床护理路径，改善CHF管理的急诊科（院前）阶段，以及改善患者教育和出院计划。
该研究表明，许多没有丰富临床研究经验的社区医院可以自愿合作，设计并实施一项及时的、基于证据、临床相关且科学合理的QI举措。初步结果使人们对心力衰竭患者的护理流程和预后决定因素有了更好的理解。该研究的第二阶段应能深入了解医疗服务提供者对本地制定的干预措施的反应，以及该计划对患者预后的影响。
