探討台灣臨床成效指標於急性心肌梗塞病人之執行現況及其預後重要預測因子

研究背景鑑於急性心肌梗塞之死亡率及醫療成本居高不下，且國內外目前對於臨床成效指標與預後相關性仍未明確，故本研究欲探討台灣臨床成效指標於急性心肌梗塞病人之執行現況及其預後重要預測因子。研究方法本研究採橫斷式病歷回溯研究設計，立意取樣於南部某醫學中心之心臟內科，樣本回溯期間為2016年7月1日至2017年7月31日，出院診斷碼為ICD-10-CM: I21.XX之急性心肌梗塞病人。資料收集及彙整時間由2018年4月1日至2018年6月30日，初篩樣本為716人，依據台灣臨床成效指標原則，以住院中死亡及14天內再住院作為預後指標，經共同排除條件後，分別納入431位及396位病人，分析其指標執行現況，並透過邏輯式迴歸探討預後重要預測因子。研究結果單變項邏輯式迴歸分析結果顯示，女性、≧70歲、未具1年內吸菸史、Killip分級III-IV、低密度脂蛋白膽固醇<100mg/dL、左心室射血分率＜40%及急診6小時內未予雙重血小板抑制劑具較高住院中死亡風險。性別(OR= 0.045；P= 0.020)、年齡(OR= 3.318；P= 0.001)、1年內吸菸史(OR= 0.210；P= 0.004)、Killip分級(OR= 6.823；P= 0.000)、低密度脂蛋白膽固醇(OR= 0.414；P= 0.033)、左心室射血分率(OR= 2.966；P= 0.009)及急診6小時內是否予雙重血小板抑制劑(OR= 6.141；P= 0.040)可作為本研究住院中死亡之預測因子。而Killip分級I-II則具較高14天內再住院風險。Killip分級(OR= 0.170；P= 0.022)可作為本研究14天內再住院之獨立預測因子。多變項邏輯式迴歸分析結果顯示，≧70歲及Killip分級III-IV具較高住院中死亡風險。年齡(OR= 2.702；P= 0.026)及Killip分級(OR= 5.203；P= 0.000)可作為本研究住院中死亡之獨立預測因子。結論據本研究結果可知，≧70歲及Killip分級III-IV者，具較高住院中死亡風險，於住院時應嚴謹監測疾病狀況；而Killip分級I-II者縱然住院中死亡風險較低，卻具較高14天內再住院風險，除住院天數較短，出院後自覺疾病嚴重程度較低與醫囑遵從性低，進而增加14天內再住院風險。因此建議未來醫療機構可發展完善追蹤計畫，以提供持續性照護，增進疾病預後。關鍵詞：急性心肌梗塞、台灣臨床成效指標、預後

關鍵字

急性心肌梗塞；台灣臨床成效指標；預後

並列摘要

Background The high mortality and medical costs of acute myocardial infarction (AMI) are major issues in Taiwan. Previous studies indicated the effectiveness of clinic performance indicator and predictors of AMI was unclear. The aim of the study is to explore the current application of Taiwan clinic performance indicator and predictors of prognosis in acute myocardial infarction. Methods A retrospective and cross-sectional study was conducted. Purposive sampling was used to enroll subjects from a Cardiology Department in a medical center in southern Taiwan. The discharge diagnosis code was ICD-10-CM: I21.XX of subjects from July 2016 to July 2017 were involved. Data were extracted from April 2018 to June 2018. Afterwards, 716 subjects were enrolled. Based on the exclusion criteria of the in-hospital mortality and 14-day hospital readmission of Taiwan Clinical Performance Indicators, 431 and 396 subjects were enrolled in this study, respectively. Logistic regression was used to identify “independent predictors” of these two indicators. Results In regard to the univariate logistic regression analysis, female, ≧70-year old, either no smoking history or quitting smoking for 1 year, Killip class III-IV, LDL-C<100mg/dL, LVEF＜40% and no DAPT administratio- n within 6 hours in the emergency department were identified having significantly high risk in in-hospital mortality. Gender (OR= 0.045; P= 0.020), age (OR= 3.318; P= 0.001), smoking history within 1 year (OR= 0.210; P= 0.004), Killip class (OR= 6.823; P= 0.000), LDL-C (OR= 0.414; P= 0.033), LVEF (OR= 2.966; P= 0.009) and whether DAPT administration within 6 hours in the emergency department (OR= 6.141; P= 0.040) were the predictors of in-hospital mortality. However, Killip class I-II was identified having significantly high risk in 14-day hospital readmission. Killip class (OR= 0.170; P = 0.022) was an independent predictor of 14-day hospital readmission. In regard to the multivariate logistic regression analysis, ≧70-year old and Killip class III-IV were identified having significantly high risk in in-hospital mortality. Age (OR= 2.702; P=0.026) and Killip class (OR= 5.203; P= 0.000) were the independent predictors of in-hospital mortality. Conclusion According to the above results, both of ≧70-year old and Killip class III-IV had higher in-hospital mortality in AMI patients. Disease condition of these subjects should be closely monitored to reduce such mortality. However, Killip class I-II had higher 14-day hospital readmission in AMI patients. These subjects had lower in-hospital mortality. It may be due to shorter length of stay, lower illness perception, and lower medical compliance in AMI. Therefore, to develop a follow-up program in medical institutions to provide continuous care and improve prognosis is needed in the future. Keywords: Acute Myocardial Infarction; Taiwan Clinic Performance Indicator; Prognosis; Outcome