The effectiveness of right heart catheterization in the initial care of critically ill patients
The effectiveness of right heart catheterization in the initial care of critically ill patients
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DOI：
10.1001/jama.276.11.889
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发表时间：
1996-09-18
影响因子：
120.7
通讯作者：
Knaus, WA
中科院分区：
文献类型：
--
作者：
Connors, AF;Speroff, T;Knaus, WA
目的：研究重症监护病房(ICU)头24小时内右心导管(RHC)的使用与随后的存活期、住院时间、护理强度和护理成本之间的关系。设计：前瞻性队列研究。设置：1989至1994年间的五家美国教学医院。研究对象：共有5735名危重成人患者在ICU接受9种预先指定的疾病类别中的一种的护理。主要结果衡量标准：根据临床记录和国家死亡指数确定的存活时间、护理成本、护理强度和在ICU和医院的住院时间。使用多变量Logistic回归建立RHC的倾向评分，使用病例匹配和多变量回归建模技术估计RHC与使用倾向评分调整治疗选择后的特定结果的相关性。结果：通过病例匹配分析，RHC患者的30天死亡率增加(优势比1.24；95%可信区间1.03-1.49)。每次住院的平均成本(第25、50、75百分位数)分别为49 300元(17 000元、30 500元、56 600元)和35 700元(11 300元、20 600元、39 200元)。平均住ICU天数：RHC为14.8(5，9，17)天，RHC为13.0(4，7，14)天。这些发现都被多变量建模技术所证实。亚组分析没有发现任何患者组或部位的RHC与改善的结果相关。存活2个月的基线概率较高的患者在RHC后死亡的相对风险最高。敏感性分析表明，缺失的协变量必须将死亡风险增加6倍，RHC风险增加8倍，RHC的真正有益效果才会被错误地描述为有害的。结论-在这项针对危重患者的观察性研究中，在对治疗选择偏向进行调整后，RHC与死亡率增加和资源利用增加有关。这种明显缺乏益处的原因尚不清楚。这一分析的结果应该在其他观察性研究中得到证实。这些发现证明了重新考虑RHC的随机对照试验的合理性，并可能指导此类研究的患者选择。
Objective.-To examine the association between the use of right heart catheterization (RHC) during the first 24 hours of care in the intensive care unit (ICU) and subsequent survival, length of stay, intensity of care, and cost of care.Design.-Prospective cohort study.Setting.-Five US teaching hospitals between 1989 and 1994.Subjects.-A total of 5735 critically ill adult patients receiving care in an ICU for 1 of 9 prespecified disease categories.Main Outcome Measures.-Survival time, cost of care, intensity of care, and length of stay in the ICU and hospital, determined from the clinical record and from the National Death Index, A propensity score for RHC was constructed using multivariable logistic regression, Case-matching and multivariable regression modeling techniques were used to estimate the association of RHC with specific outcomes after adjusting for treatment selection using the propensity score. Sensitivity analysis was used to estimate the potential effect of an unidentified or missing covariate on the results.Results.-By case-matching analysis, patients with RHC had an increased 30-day mortality (odds ratio, 1.24; 95% confidence interval, 1.03-1.49). The mean cost (25th, 50th, 75th percentiles) per hospital stay was $49 300 ($17 000, $30 500, $56 600) with RHC and $35 700 ($11 300, $20 600, $39 200) without RHC. Mean length of stay in the ICU was 14.8 (5, 9, 17) days with RHC and 13.0 (4, 7, 14) days without RHC. These findings were all confirmed by multivariable modeling techniques. Subgroup analysis did not reveal any patient group or site for which RHC was associated with improved outcomes. Patients with higher baseline probability of surviving 2 months had the highest relative risk of death following RHC. Sensitivity analysis suggested that a missing covariate would have to increase the risk of death 6-fold and the risk of RHC 8-fold for a true beneficial effect of RHC to be misrepresented as harmful.Conclusion.-In this observational study of critically ill patients, after adjustment for treatment selection bias, RHC was associated with increased mortality and increased utilization of resources. The cause of this apparent lack of benefit is unclear. The results of this analysis should be confirmed in other observational studies. These findings justify reconsideration of a randomized controlled trial of RHC and may guide patient selection for such a study.