Association of Hospital Performance Based on 30-Day Risk-Standardized Mortality Rate With Long-term Survival After Heart Failure Hospitalization An Analysis of the Get With The Guidelines-Heart Failure Registry
Association of Hospital Performance Based on 30-Day Risk-Standardized Mortality Rate With Long-term Survival After Heart Failure Hospitalization An Analysis of the Get With The Guidelines-Heart Failure Registry
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DOI：
10.1001/jamacardio.2018.0579
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发表时间：
2018-06-01
期刊：
影响因子：
24
通讯作者：
Fonarow, Gregg C.
中科院分区：
文献类型：
--
作者：
Pandey, Ambarish;Patel, Kershaw, V;Fonarow, Gregg C.
在心力衰竭（HF）住院患者中，基于30天风险标准化死亡率（RSMRs）的住院治疗的长期临床意义尚不清楚。目的：在美国心脏协会指南-心衰登记中，评估住院心衰患者的医院特异性30天RSMR与长期生存的关系。设计、环境和参与者：这项纵向观察性研究纳入了106304例心衰患者，这些患者从2005年1月1日至2013年12月31日在317个中心参与了心衰指南注册，并有医疗保险相关的随访数据。医院特定的30天RSMR使用分层逻辑回归模型计算。在模型中，30天死亡率为二元结果，患者基线特征作为协变量，医院作为随机效应。使用调整后的Cox模型评估基于30天RSMR的医院组（从低到高的30天RSMR：四分位数1 [Q1]至Q4）与长期（1年、3年和5年）死亡率的关系。数据分析时间为2017年6月29日至2018年2月19日。参与医院的30天RSMR。主要结局和测量：1年、3年和5年死亡率。结果106 304例患者纳入分析。57 552例（54.1%）为女性，84 595例（79.6%）为白人，年龄中位数（四分位数间距）为81（74-87）岁。30天RSMR从8.6%（01）到10.7% （Q4）不等。低30天RSMR组的医院更容易获得先进的心衰治疗、心脏手术和经皮冠状动脉介入治疗。在30天存活者的主要标志性分析中，30天RSMR与长期死亡率呈分级负相关（Q1 vs Q4: 5年死亡率，733% vs 76.8%）。在调整分析中，30天RSMR高组住院患者的5年死亡率相对危险度比30天RSMR低组住院患者高14% （95% CI, 10-18）。在入院后的生存分析中也观察到类似的发现，Q4医院与Q1医院相比，患者5年死亡率的相对危险度高22% （95% CI, 18-26）。结论和相关性较低的医院水平30天RSMR与HF患者较高的1年、3年和5年生存率相关。这些30天生存率的差异在30天之后继续累积，并长期存在，这表明30天RSMR可能是一个有用的心衰表现指标，以激励高质量的护理和改善长期预后。
IMPORTANCE Among patients hospitalized with heart failure (HF), the long-term clinical implications of hospitalization at hospitals based on 30-day risk-standardized mortality rates (RSMRs) is not known.OBJECTIVE To evaluate the association of hospital-specific 30-day RSMR with long-term survival among patients hospitalized with HF in the American Heart Association Get With The Guidelines-HF registry.DESIGN, SETTING, AND PARTICIPANTS The longitudinal observational study included 106 304 patients with HF who were admitted to 317 centers participating in the Get With The Guidelines-HF registry from January 1, 2005, to December 31, 2013, and had Medicare-linked follow-up data. Hospital-specific 30-day RSMR was calculated using a hierarchical logistic regression model. In the model, 30-day mortality rate was a binary outcome, patient baseline characteristics were included as covariates, and the hospitals were treated as random effects. The association of 30-day RSMR-based hospital groups (low to high 30-day RSMR: quartile 1 [Q1) to Q4) with long-term (1-year, 3-year, and 5-year) mortality was assessed using adjusted Cox models. Data analysis took place from June 29, 2017, to February 19, 2018.EXPOSURES Thirty-day RSMR for participating hospitals.MAIN OUTCOMES AND MEASURES One-year, 3-year, and 5-year mortality rates.RESULTS Of the 106 304 patients included in the analysis. 57 552 (54.1%) were women and 84 595 (79.6%) were white, and the median (interquartile range) age was 81(74-87) years. The 30-day RSMR ranged from 8.6% (01) to 10.7% (Q4). Hospitals in the low 30-day RSMR group had greater availability of advanced HF therapies, cardiac surgery, and percutaneous coronary interventions. In the primary landmarked analyses among 30-day survivors, there was a graded inverse association between 30-day RSMR and long-term mortality (Q1 vs Q4: 5-year mortality, 733% vs 76.8%). In adjusted analysis, patients admitted to hospitals in the high 30-day RSMR group had 14% (95% CI, 10-18) higher relative hazards of 5-year mortality compared with those admitted to hospitals in the low 30-day RSMR group. Similar findings were observed in analyses of survival from admission, with 22% (95% CI, 18-26) higher relative hazards of 5-year mortality for patients admitted to Q4 vs Q1 hospitals.CONCLUSIONS AND RELEVANCE Lower hospital-level 30-day RSMR is associated with greater 1-year, 3-year, and 5-year survival for patients with HF. These differences in 30-day survival continued to accrue beyond 30 days and persisted long term, suggesting that 30-day RSMR may be a useful HF performance metric to incentivize quality care and improve long-term outcomes.