背景:随着非ST段抬高型心肌梗死(NSTEMI)负担的增加,发展中国家在提供全国公平待遇方面面临巨大挑战。然而,对中国NSTEMI护理质量的医院水平差异知之甚少。我们旨在调查三个医院级别的NSTEMI护理和患者预后的变化(省份-,县级和县级,规模递减)在中国。
方法:数据来源于2013年1月至2016年11月中国大陆31个省市连续登记的NSTEMI患者的中国急性心肌梗死登记处。根据入院的医院级别对患者进行分类。拟合了多级广义混合模型,以检查医院级别与院内死亡风险之间的关系。
结果:总计,纳入了8,054例NSTEMI患者(省级:1,698例患者;地级:5,240例患者;县级:1,116例患者)。县级和县级医院的患者年龄较大,更有可能是女性,心功能低于省级医院(P<0.05)。与省级医院相比,在县级和县级医院中,侵入性策略的发生率明显较低(分别为65.3、43.3和15.4%,分别,P<0.001)。在25.4、9.7和1.7%的极高危患者中,在指南推荐的时间范围内进行了侵入性策略。和16.4%、7.4%和2.4%的高危患者,县级医院,分别(均P<0.001)。县级医院使用双联抗血小板治疗(87.2%)与省级医院(94.5%,P<0.001)和地市级医院(94.5%,P<0.001)。从省级到县级医院,医院内死亡率呈递增趋势(3.0、4.4和6.9%,分别,P-趋势<0.001)。在逐步调整患者特征后,介绍,医院设施和住院治疗,在完全调整的模型中,医院级别的死亡率风险差距逐渐缩小并失去统计意义[赔率:省级别与地级:1.23(0.73-2.05),P=0.441;省级与县级:1.61(0.80-3.26),P=0.182;P-趋势=0.246]。
结论:中国三家医院的NSTEMI表现和治疗模式存在显著差异,这可能在很大程度上解释了医院死亡率的差异。有必要采取质量改进措施,尤其是下级医院。
BACKGROUND: With the growing burden of non-ST-elevation myocardial infarction (NSTEMI), developing countries face great challenges in providing equitable treatment nationwide. However, little is known about hospital-level disparities in the quality of NSTEMI care in
China. We aimed to investigate the variations in NSTEMI care and patient outcomes across the three hospital levels (province-, prefecture- and county-level, with decreasing scale) in
China.
METHODS: Data were derived from the
China Acute Myocardial Infarction Registry on patients with NSTEMI consecutively registered between January 2013 and November 2016 from 31 provinces and municipalities throughout mainland
China. Patients were categorized according to the hospital level they were admitted to. Multilevel generalized mixed models were fitted to examine the relationship between the hospital level and in-hospital mortality risk.
RESULTS: In total, 8,054 patients with NSTEMI were included (province-level: 1,698 patients; prefecture-level: 5,240 patients; county-level: 1,116 patients). Patients in the prefecture- and county-level hospitals were older, more likely to be female, and presented worse cardiac function than those in the province-level hospitals (P <0.05). Compared with the province-level hospitals, the rate of invasive strategies was significantly lower in the prefecture- and county-level hospitals (65.3, 43.3, and 15.4%, respectively, P <0.001). Invasive strategies were performed within the guideline-recommended timeframe in 25.4, 9.7, and 1.7% of very-high-risk patients, and 16.4, 7.4, and 2.4% of high-risk patients in province-, prefecture- and county-level hospitals, respectively (both P <0.001). The use of dual antiplatelet therapy in the county-level hospitals (87.2%) remained inadequate compared to the province- (94.5%, P <0.001) and prefecture-level hospitals (94.5%, P <0.001). There was an incremental trend of in-hospital mortality from province- to prefecture- to county-level hospitals (3.0, 4.4, and 6.9%, respectively, P-trend <0.001). After stepwise adjustment for patient characteristics, presentation, hospital facilities and in-hospital treatments, the hospital-level gap in mortality risk gradually narrowed and lost statistical significance in the fully adjusted model [Odds ratio: province-level vs. prefecture-level: 1.23 (0.73-2.05), P = 0.441; province-level vs. county-level: 1.61 (0.80-3.26), P = 0.182; P-trend = 0.246].
CONCLUSIONS: There were significant variations in NSTEMI presentation and treatment patterns across the three hospital levels in
China, which may largely explain the hospital-level disparity in in-hospital mortality. Quality improvement initiatives are warranted, especially among lower-level hospitals.