Association Between Hospital Volume, Processes of Care, and Outcomes in Patients Admitted With Heart Failure Insights From Get With The Guidelines-Heart Failure
Association Between Hospital Volume, Processes of Care, and Outcomes in Patients Admitted With Heart Failure Insights From Get With The Guidelines-Heart Failure
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DOI：
10.1161/circulationaha.117.028077
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发表时间：
2018-04-17
期刊：
影响因子：
37.8
通讯作者：
Bhatt, Deepak L.
中科院分区：
文献类型：
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作者：
Kumbhani, Dharam J.;Fonarow, Gregg C.;Bhatt, Deepak L.
背景技术背景：医院容量经常被用作评估护理质量的结构性指标，但其在急性心力衰竭（HF）患者中的效用尚未得到很好的表征。因此，我们试图确定入院量之间的关系，过程的护理指标，并在急性HF.METHODS：患者入院的短期和长期的结果与获得的指南，HF注册与链接的医疗保险住院数据在342家医院进行了评估。将体积作为连续变量进行评估，并基于入院的年度HF病例体积进行四分位数评估：5至38（四分位数1）、39至77（四分位数2）、78至122（四分位数3）、123至457（四分位数4）。主要结局指标为（1）出院时的过程指标（HF实现、质量、报告和复合指标）;（2）30天死亡率和再次入院;（3）6个月死亡率和再次入院。调整后的logistic和考克斯比例风险模型被用来研究这些协会与医院volume.Results：共125 595例HF患者被纳入。高容量医院的患者有更高的合并症负担。在多变量建模，低容量的医院显着不太可能遵守HF过程的措施比高容量的医院。较高的住院量与住院期间的差异无关。（比值比，0.99; 95%置信区间[CI]，0.94-1.05; P=0.78）或30天死亡率（风险比，0.99; 95%CI，0.97-1.01; P=0.26）或30天再入院（风险比，0.99; 95%CI，0.97-1.00; P=0.10）。高容量与低6个月死亡率之间存在弱相关性（风险比，0.98; 95% CI，0.97-0.99; P=0.001）和较低的6个月全因再入院率（风险比，0.98; 95%，CI 0.97-1.00; P=0.025）。我们对一个大型的当代前瞻性国家质量改进老年HF患者登记研究的分析表明，医院容量作为一个结构性指标与过程指标相关，但与30天结局无关，并且在长达6个月的随访结果中仅有轻微的变化。医院分析应侧重于参与护理系统，遵守流程指标和风险标准化的结果，而不是医院数量本身。
BACKGROUND: Hospital volume is frequently used as a structural metric for assessing quality of care, but its utility in patients admitted with acute heart failure (HF) is not well characterized. Accordingly, we sought to determine the relationship between admission volume, process-of-care metrics, and short-and long-term outcomes in patients admitted with acute HF.METHODS: Patients enrolled in the Get With The Guidelines-HF registry with linked Medicare inpatient data at 342 hospitals were assessed. Volume was assessed both as a continuous variable, and quartiles based on the admitting hospital annual HF case volume, as well: 5 to 38 (quartile 1), 39 to 77 (quartile 2), 78 to 122 (quartile 3), 123 to 457 (quartile 4). The main outcome measures were (1) process measures at discharge (achievement of HF achievement, quality, reporting, and composite metrics); (2) 30-day mortality and hospital readmission; and (3) 6-month mortality and hospital readmission. Adjusted logistic and Cox proportional hazards models were used to study these associations with hospital volume.RESULTS: A total of 125 595 patients with HF were included. Patients admitted to high-volume hospitals had a higher burden of comorbidities. On multivariable modeling, lower-volume hospitals were significantly less likely to be adherent to HF process measures than higher-volume hospitals. Higher hospital volume was not associated with a difference in in-hospital (odds ratio, 0.99; 95% confidence interval [CI], 0.94-1.05; P=0.78) or 30-day mortality (hazard ratio, 0.99; 95% CI, 0.97-1.01; P=0.26), or 30-day readmissions (hazard ratio, 0.99; 95% CI, 0.97-1.00; P=0.10). There was a weak association of higher volumes with lower 6-month mortality (hazard ratio, 0.98; 95% CI, 0.97-0.99; P=0.001) and lower 6-month all-cause readmissions (hazard ratio, 0.98; 95%, CI 0.97-1.00; P=0.025).CONCLUSIONS: Our analysis of a large contemporary prospective national quality improvement registry of older patients with HF indicates that hospital volume as a structural metric correlates with process measures, but not with 30-day outcomes, and only marginally with outcomes up to 6 months of follow-up. Hospital profiling should focus on participation in systems of care, adherence to process metrics, and risk-standardized outcomes rather than on hospital volume itself.