The Association between Hospital Quality of Care and Short-Term Mortality of Acute Myocardial Infarction Patients

醫院照護過程品質與急性心肌梗塞病人死亡之相關性

譚家惠(Chia-Hui Tan) ； 譚醒朝(Sing-Chew Tam) ； 楊銘欽(Ming-Chin Yang)

《台灣公共衛生雜誌》 32卷3期 (2013/06) Pp. 289-301

https://doi.org/10.6288/TJPH2013-32-03-10

摘要

目標：評估急性心肌梗塞6項醫院照護過程品質測量與病人出院後30天內死亡情形之相關性。方法：採橫斷性研究，以2007年1月至2009年11月住院主診斷為急性心肌梗塞病人（ICD-9 CM: 410.xx），排除後續治療者（ICD-9 CM: 410.x2），以廣義階層線性模式（HGLM）分析醫院層次的6項照護過程品質測量，對於病人出院後30天內死亡情形之相關性。結果：約85.5%的病人在住院期間曾接受aspirin治療、38.32%曾接受beta-blocker治療、46.75%曾接受ACE inhibitor for LVSD治療、43.91%曾接受低密度膽固醇檢查、41.37%曾接受血管再通術。經病人特質與醫院特質校正後，醫院住院期間beta-blocker使用情形（OR, 0.87; 95% CI, 0.83-0.92）、ACE inhibitor for LVSD使用情形（OR, 0.93; 95% CI, 0.87-0.99）、低密度膽固醇檢查執行情形（OR, 0.87; 95% CI, 0.81-0.93）、血管再通術使用情形（OR, 0.87; 95% CI, 0.81-0.93），以及6項品質測量的綜合分數（OR, 0.84; 95% CI, 0.76-0.92），對於病人出院後30天內死亡風險有顯著影響。結論：醫院照護過程品質測量對於急性心肌梗塞病人出院後30天內死亡風險有顯著影響，且醫院層次照護過程品質測量的應用與改善，將有助於急性心肌梗塞病人照護結果。

關鍵字

照護品質 ； 急性心肌梗塞 ； 醫院照護過程 ； 廣義階層線性模式

並列摘要

Objectives: To evaluate the association of six hospital-level process of care measures and the 30-day mortality. Methods: This is a cross-sectional study. Patients admitted with a principal diagnosis of AMI (ICD-9CM: 410.xx, excluding 410.x2) (n=1,416) between January 2007 and November 2009. Aspirin use during hospitalization, β-blocker use during hospitalization, ACE inhibitor for LVSD use during hospitalization, LDL-c testing, lipid lowering medication, and reperfusion therapy. Outcome included the 30-day mortality of AMI patients. Data were analysed by using a hierarchical generalized linear model (HGLM) to examine whether the 30-day mortality at the patient level varied among different hospital performance adjusted for patient and hospital characteristics. Results: Among those patients, 88.50% received aspirin therapy during hospitalization, 38.32% received β-blocker therapy, 46.75% received ACE inhibitor for LVSD, 43.91% received LDL-C testing, 41.37% received lipid lowering medication, and 40.97% received reperfusion therapy. Overall the 6 quality of care measures were 53.7% of ideal instances. After risk adjustment, β-blocker use during hospitalization (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.83-0.92), ACE inhibitor for LVSD (OR, 0.93; 95% CI, 0.87-0.99), lipid lowering medication (OR, 0.91; 95% CI, 0.86-0.96), reperfusion therapy (OR, 0.87; 95% CI, 0.81-0.93) and composite score of six measures (OR, 0.84; 95% CI, 0.76-0.92) were significantly correlated with 30-day mortality. Conclusions: A significant association between hospital's process performance and patient outcome was found. The outcome of AMI patients could be enhanced by improving process performance.

並列關鍵字

quality of care ； acute myocardial infarction (AMI) ； hospital process performance ； hierarchical generalized linear model (HGLM)

參考文獻

Department of Health, Executive Yuan, R.O.C. (Taiwan). Statistics of Causes of Death. Taipei: Department of Health, Executive Yuan, R.O.C. (Taiwan)

(National Health Insurance Research Database. Data subsets. Available at: http://w3.nhri.org.tw/nhird/en/Data_Subsets.html#S3. Accessed July 28, 2010).http://w3.nhri.org.tw/nhird/en/Data_Subsets.html#S3

Antman, E.M.,Anbe, D.T.,Armstrong, P.W.(2004).ACC/AHA guidelines for the management of patients with st-elevation myocardial infarction - executive summary. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (writing committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction).J Am Coll Cardiol.44,671-719.

Austin, P.C.,Tu, J.V.,Alter, D.A.(2003).Comparing hierarchical modeling with traditional logistics regression analysis among patients hospitalized with acute myocardial infarction: should we be analyzing cardiovascular outcomes data differently?.Am Heart J.145,27-35.

Barnato, A.E.,Lucas, F.L.,Staiger, D.,Wennberg, D.E.,Chandra, A.(2005).Hospital-level racial disparities in acute myocardial infarction treatment and outcomes.Med Care.43,308-19.