The Quality of Care Provided to Patients With Varices in the Department of Veterans Affairs
The Quality of Care Provided to Patients With Varices in the Department of Veterans Affairs
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DOI：
10.1038/ajg.2013.487
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发表时间：
2014-07-01
影响因子：
9.8
通讯作者：
Kanwal, Fasiha
中科院分区：
文献类型：
--
作者：
Buchanan, Paula M.;Kramer, Jennifer R.;Kanwal, Fasiha
注意事项：实践指南定义了肝硬化和静脉曲张患者的护理标准和标准。然而，患者接受推荐治疗的程度在很大程度上是未知的。我们评估了静脉曲张相关的护理质量和相关因素，收到这样的care.METHODS：我们进行了一项回顾性队列研究，550例肝硬化患者谁寻求护理在2000年和2007年之间的三个VA设施。使用管理和临床数据，我们评估了静脉曲张护理质量，通过八个明确的德尔菲小组得出的质量指标进行测量。我们还进行了一个结构化的隐式审查患者的医疗记录，以探讨患者的拒绝，接收VA以外的护理，或合理的排除某些护理过程的作用，作为解释不遵守质量指标。100%）在各个指标之间存在差异，范围从用于静脉曲张筛查的上消化道内镜检查的24.3%到用于静脉曲张出血二级预防的72.4%。在静脉曲张患者的一级预防、接受内镜检查和活动性出血患者的内镜治疗中，图表中记录的合理排除适应症治疗是常见的。相比之下，在接受筛选内镜检查、使用β受体阻滞剂（在没有静脉曲张的情况下）、使用生长抑素类似物、抗生素和静脉曲张出血患者的二级预防方面仍存在显著不足。年轻患者（<< 60 vs. >60岁，比值比（OR）= 1.29，95%置信区间（CI）1.01-1.68），看过胃肠病医生的患者（OR = 1.55，95%CI = 1.09-2.21），或在该机构中有学术联系的人（OR = 1.26，95%CI = 1.01-1.58）接受了更高质量的护理。结论：根据患者是否接受了推荐的静脉曲张相关护理来衡量的医疗保健质量在该医疗保健环境中是次优的。包括胃肠病学家在内的护理与高质量相关。
OBJECTIVES: Practice guidelines define the criteria and standards of care in patients with cirrhosis and varices. However, the extent to which the patients receive recommended care is largely unknown. We evaluated the quality of varices related care and factors associated with receipt of such care.METHODS: We conducted a retrospective cohort study of 550 patients with cirrhosis who sought care at three VA facilities between 2000 and 2007. Using administrative and clinical data, we assessed quality of varices care as measured by eight explicit Delphi panel-derived quality indicators. We also conducted a structured implicit review of patients 'medical records to explore the role of patients' refusal, receipt of care outside the VA, or justifiable exclusions to certain care processes as explanations for non-adherence to the quality indicators.RESULTS: Quality scores (max. 100 %) varied across individual indicators, ranging from 24.3 % for upper endoscopy for varices screening to 72.4 % for secondary prophylaxis for variceal bleeding. Justifiable exclusions to indicated care documented in charts were common for primary prophylaxis in patients with varices; receipt of endoscopy; and endoscopic treatment in patients with active bleeding. In contrast, significant shortfalls remained in the receipt of screening endoscopy, use of beta-blockers (in the absence of varices), and use of somatostatin analogs, antibiotics, and secondary prophylaxis in patients with variceal bleeding. Younger patients (< 60 vs. > 60 year, odds ratio (OR) = 1.29, 95 % confidence interval (CI) 1.01-1.68), those who saw a gastroenterologist (OR = 1.55, 95 % CI = 1.09-2.21), or those who were seen in the facility with academic affiliation (OR = 1.26, 95 % CI = 1.01-1.58) received higher quality care.CONCLUSIONS: Health-care quality, measured according to whether patients received recommended varices-related care, was suboptimal in this health-care setting. Care that included gastroenterologists was associated with high quality.