RIGHT HEART CATHETERIZATION: OUTCOMES AND EFFECTIVENESS

1993年，共施行右心导管术120万次 在美国花费超过24亿美元用于危重患者的治疗 美元。然而，目前还没有确定RHC是否可以改善 危重病人的存活率或提高从 得了重病。事实上，没有确凿的证据表明 这一过程的大多数适应症，但没有明确的指导方针 这项技术的适当使用。因此，RHC的用法各不相同 很大程度上是在医生和医院之间。供临床执业医生使用 为了适当地起诉RHC，他们需要澄清其总体 更可能的患者亚组的有效性和识别 从这一过程中获益或受到伤害。 一个多学科研究团队将使用三个大型数据库来 确定：1)RHC在生存、功能方面的有效性 地位、生活质量和护理满意度；2)使用的变化 危重患者的RHC；3)RHC与 危重病人的资源利用。要做到这一点，三个大 将使用观察性数据库，1)设计为允许 对疾病严重程度、诊断、急性生理和其他方面的调整 重要的患者特征，2)表现出较大的医院间 RHC和30在使用上的不同是两者的重要代表 一般患病患者和目前使用RHC的情况。三位一体 数据库包括：1)克利夫兰健康质量选择项目(CHQCP) 数据库[35,000名患者/年，所有ICU从40个ICU在30 大克利夫兰地区的医院]；2)阿帕奇III数据库 [来自全国40家医院42个ICU的17,440名患者]；以及 3)支助数据库[来自5家医院的9105名重病患者 有15个ICU]。RHC的有效性将在以下方面进行评估 生存、功能状态、生活质量和患者满意度。 为了调整选择偏差，将对执行RHC的决定进行建模 使用所有影响临床医生决策的协变量 执行RHC或感兴趣的结果。将对有效性进行评估 通过确定RHC与术后患者预后的关系 根据执行RHC的倾向进行调整。RHC用法的变化 将对医院和单位之间的关系进行描述和检查。该协会 在RHC、住院时间和护理强度之间将进行检查 在所有三个数据库中。支持数据库将用于探索 RHC与医疗费用估算之间的关系。 当前项目的结果将与健康直接相关。 政策制定者、购买者、医疗服务购买者、医生 和他们的病人在有效使用RHC方面寻求指导，并 希望完善这种常见疾病的适应症的调查人员 和昂贵的技术。关于RHC所处环境的证据 显然适当的做法将降低进行对照试验的门槛 RHC临床适应症似乎不明确的人群。

In 1993, right heart catheterization (RHC) was performed 1.2 million times in critically ill patients in the U.S. at a cost exceeding 2.4 billion dollars. It has not been determined, however, whether RHC improves the survival of critically ill patients or enhances long-term recovery from a serious illness. In fact, there is no conclusive evidence of benefit for most indications for this procedure and no clear guidelines for the appropriate use of this technology. Consequently, the use of RHC varies substantially among physicians and hospitals. For practicing clinicians to sue RHC appropriately, they need clarification of its overall effectiveness and identification of patients subgroups who are more likely to either benefit from or be harmed by the procedure. A multidisciplinary research team will use three large databases to determine the: 1) effectiveness of RHC in terms of survival, functional status, quality of life, and satisfaction with care; 2) variation in use of RHC in seriously ill patients; and 3) association of RHC and utilization of resources in the critically ill. To do this, three large observational databases will be used which 1) are designed to allow adjustment for severity of illness, diagnosis, acute physiology and other important patient characteristics, 2) demonstrate large interhospital differences in use of RHC, and 30 are representative of both critically ill patients in general and of the current use of RHC. The three databases include: 1) the Cleveland Health Quality Choice Project (CHQCP) database [35,000 patients/yr, all ICU admission from 40 ICUs at 30 hospitals in the Greater Cleveland area]; 2) the APACHE III database [17,440 patients from a national sample of 40 hospitals with 42 ICUs]; and 3) the SUPPORT database [9,105 seriously ill patients from 5 hospitals with 15 ICUs]. Effectiveness of RHC will be assessed with respect to survival, functional status, quality of life, and patient satisfaction. To adjust for selection bias, the decision to perform RHC will be modeled using all covariates that either influence the clinician's decision to perform RHC or the outcomes of interest. Effectiveness will be estimated by determining the relationship between RHC and patient outcomes after adjusting for the propensity to perform RHC. Variation in the use of RHC among hospitals and units will be described and examined. The association between RHC, length of stay and intensity of nursing care will be examined in all three databases. The SUPPORT database will be used to explore the relationship between RHC and estimates of the cost of care. The results of the current project will be of direct relevance to health policymakers, to purchasers, to purchasers of medical care, to physicians and their patients who seek guidance in the effective use of RHC, and to investigators who wish to refine the indications for use of this common and expensive technology. Evidence about settings in which RHC either is clearly appropriate will lower barriers to performing controlled trials in populations for which clinical indications for RHC appear equivocal.