Stroke patient outcomes in US hospitals before the start of the Joint Commission Primary Stroke Center certification program.
Stroke patient outcomes in US hospitals before the start of the Joint Commission Primary Stroke Center certification program.
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DOI：
10.1161/strokeaha.109.561472
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发表时间：
2009-11
期刊：
影响因子：
8.3
通讯作者：
Goldstein LB
中科院分区：
文献类型：
--
作者：
Lichtman JH;Allen NB;Wang Y;Watanabe E;Jones SB;Goldstein LB
联合委员会（JC）于2003年11月开始认证初级中风中心。如果这些中心在项目开始前有更好的结果，那么评估认证影响的横断面研究可能会有偏见。我们确定了在JC计划的第一年内获得认证的医院是否比认证计划开始前的非认证医院有更好的结果。研究样本包括2002年从5070家医院出院的年龄≥65岁的缺血性卒中的医疗保险按服务收费受益人，其中317家医院在2007年6月前获得JC认证。分层逻辑回归和考克斯比例风险模型用于比较在未来JC认证与非认证医院治疗的患者的院内和30天死亡率和30天再入院率。在366，551名患者中，18%（66，300人）在该计划的最初几年内在拥有JC认证中心的医院接受治疗。这些患者更年轻，更可能是白色和男性，并且在前一年内合并症和住院较少。在未来JC认证的医院中，未调整的住院死亡率（4.7% vs. 5.5%）、30天死亡率（9.8% vs. 11.3%）和再入院率（13.8% vs. 14.6%）均较低（均p<0.001）。这些差异在风险调整后仍然存在（住院死亡率，OR=0.93，95%CI 0.90-0.96; 30天死亡率，OR=0.92，95%CI 0.87-0.96; 30天再入院，HR=0.97，95%CI 0.95-0.99）。即使在项目开始之前，JC初级中风中心认证的医院也比非认证医院有更好的结果。评估卒中中心认证效果的横断面研究需要考虑这些预先存在的差异。
The Joint Commission (JC) began certifying Primary Stroke Centers in November, 2003. Cross-sectional studies assessing the impact of certification could be biased if these centers had better outcomes prior to the start of the program. We determined whether hospitals certified within the first years of the JC program had better outcomes than non-certified hospitals prior to the start of the certification program. The study sample included Medicare fee-for-service beneficiaries ≥65 years of age discharged with ischemic stroke in 2002 from 5070 hospitals, 317 of which were JC-certified by June, 2007. Hierarchical logistic regression and Cox proportional hazards models were used to compare in-hospital and 30-day mortalities and 30-day readmission for patients treated at future JC-certified versus non-certified hospitals. Among 366,551 patients, 18% (66,300) were treated at hospitals with centers that were JC-certified within the first few years of the program. These patients were younger, more likely to be white and male, and had fewer comorbidities and hospitalizations within the prior year. Unadjusted in-hospital mortality (4.7% vs. 5.5%), 30-day mortality (9.8% vs. 11.3%) and readmissions (13.8% vs. 14.6%) were lower in the future JC-certified hospitals (all p<0.001). These differences remained after risk adjustment (in-hospital mortality, OR=0.93, 95%CI 0.90–0.96; 30-day mortality, OR=0.92, 95%CI 0.87–0.96; 30-day readmission, HR=0.97, 95%CI 0.95–0.99). JC Primary Stroke Center-certified hospitals had better outcomes than non-certified hospitals even before the program began. Cross-sectional studies assessing the effects of stroke center certification need to account for these pre-existing differences.