Improving use of peri-operative beta-blockers with a multidimentional QI program

描述（由申请人提供）：每年有数十万患者接受重大非心脏手术。在患者经历的无数并发症中，术后心脏并发症尤其成问题。在多达30%的高危患者中，术后心肌梗死、不稳定型心绞痛、充血性心力衰竭和室性心律失常与20%的死亡率相关，并导致额外的非心脏并发症。越来越多的文献支持围手术期肾上腺素能调节（特别是使用β受体阻滞剂）作为降低非心脏手术心脏并发症风险的一种方法。尽管文献不断发展，但围手术期β受体阻滞剂（PBB）对心脏风险较高（例如估计风险>4%）的患者有效，尤其是在术前开始PBB并在术后至少持续7天时。根据目前的证据，围手术期β-阻滞是LeapFrog购买计划的关键要素，也是CMS赞助的外科护理改善（SCIP）国家项目的一项战略。我们提出了一个多学科的质量改进计划，将提高标准的质量改进方法与社会营销（SM）的原则，作为一个关键的方法来评估和克服社会障碍，以改善多溴联苯在加州大学旧金山分校医疗中心的使用。我们的研究有三个目标。首先，我们将通过收集符合PBB治疗条件的患者和不符合条件的患者的数据，评估我们的项目对适当PBB给药率的影响。鉴于最近的数据表明，对不符合条件的患者使用多溴联苯可能有害，后一种人群尤其重要。其次，我们将通过评价获益（如术后心肌梗死）和潜在损害（如PBB引起的支气管痉挛）的金标准结局，评价PBB治疗在合格患者中的有效性。第三，通过我们的多学科共同调查员和顾问小组的工作，我们将开发和传播一套可广泛推广的工具，这些工具有助于制定基于社会营销的多方面预算编制干预措施，并有助于收集有效的多方面预算编制成效数据。这套工具的影响将是巨大的，因为NSQIP，SCIP，国家质量论坛和Leapfrog Group等团体继续支持PBB作为降低手术发病率和死亡率的关键战略。

DESCRIPTION (provided by applicant): Hundreds of thousands of patients undergo major noncardiac surgery every year. Of the myriad complications patients experience, postoperative cardiac complications are particularly problematic. Occurring in as many as 30% of high risk patients, postoperative myocardial infarction, unstable angina, congestive heart failure, and ventricular arrhythmias are associated with a 20% mortality, and lead to additional non-cardiac complications. A growing literature supports perioperative adrenergic modulation (particularly use of beta-blockers) as a way to reduce the risk for cardiac complications of non-cardiac surgery. Although the literature continues to evolve, perioperative beta-blockade (PBB) is effective in patients at higher cardiac risk (e.g. estimated risk >4%), especially when PBB is started preoperatively and continued at least 7 days after surgery. Based on strength of current evidence, perioperative beta-blockade is a key element of the LeapFrog purchasing initiative, and a strategy in the CMS-sponsored Surgical Care Improvement (SCIP) national project. We propose a multidisciplinary quality improvement program that will enhance standard quality- improvement methodology with social marketing (SM) principles as a key approach to assessing and overcoming social barriers to improving PBB use at UCSF Medical Center. Our research has 3 aims. First, we will evaluate the effect of our program on rates of appropriate PBB administration by collecting data from patients who are eligible for PBB therapy as well as patients who are ineligible. This latter population is particularly important given recent data suggesting that PBB use in ineligible patients may be harmful. Second, we will evaluate the effectiveness of PBB therapy in eligible patients through evaluation of gold- standard outcomes of benefit (e.g. postoperative myocardial infarction) as well as potential harm (e.g. bronchospasm due to PBB). Third, through the work of our multidisciplinary team of coinvestigators and advisors we will develop and disseminate broadly generalizable set of tools useful in developing social marketing-informed PBB interventions, as well as tools useful in collecting valid PBB effectiveness data. The impact of this set of tools will be substantial as groups such as the NSQIP, SCIP, National Quality Forum, and Leapfrog Group continue to endorse PBB as a key strategy to reduce surgical morbidity and mortality.