Outcomes and the quality of care for patients hospitalized with heart failure.

OBJECTIVE: The purpose of this study was to determine whether process quality indicators derived from evidence-based guidelines for heart failure patients were associated with outcome indicators (hospital mortality and readmissions). DESIGN: A retrospective cohort-study among patients discharged with a primary or secondary International Classification of Disease, 10th revision (ICD-10) heart failure code from 1 January to 31 December 1999. SETTING: The study was implemented in three Swiss academic medical centers. STUDY PARTICIPANTS: Records of 1634 patients hospitalized with heart failure were abstracted. Demographic characteristics, risk factors, symptoms and findings at admission, and discharge characteristics were recorded. Main outcome measure. Process quality indicators were derived from evidence-based guidelines, related to appropriate management and treatment of heart failure patients. Hospital mortality was measured in a chart abstraction process. Thirty-day readmissions were calculated using administrative data from hospitals. RESULTS: Among the three hospitals, 1153 patients with heart failure were eligible for this study. Mean age was 75.3 years (standard deviation 12.7) and 45.7% of patients were female. Ventricular function (VF) was determined in 69% of patients. The adjusted odds-ratios (OR) for the VF not determined were 1.74 [95% confidence interval (CI) 1.06-2.84] for hospital mortality and 0.75 (95% CI 0.47-1.18) for 30-day readmissions. Among patients with left ventricular systolic dysfunction and no contraindication to angiotensin-converting enzyme inhibitor (ACEI), 54% were prescribed target-dose ACEI or angiotensin receptor blockers at discharge, 32% received ACEI at less then target dose, and 14% received no ACEI at discharge. Adjusted ORs (95% CI) for readmissions were 0.89 (0.28-2.84) for no ACEI and 1.17 (0.56-2.43) for less than target ACEI compared with target dose. CONCLUSIONS: Among patients with heart failure, the determination of VF was associated with hospital mortality. However, process indicators derived from evidence-based guidelines were not related to early readmissions in three Swiss university hospitals.     

Age and quality of in-hospital care of patients with heart failure

BACKGROUND: Elderly patients may be at risk of suboptimal care. Thus, the relationship between age and quality of care for patients hospitalized for heart failure was examined. METHODS: A cross-sectional study based on retrospective chart review was performed among a random sample of patients hospitalized between 1996 and 1998 in the general internal medicine wards, with a principal diagnosis of congestive heart failure, and discharged alive. Explicit criteria of quality of care, grouped into three scores, were used: admission work-up (admission score); evaluation and treatment during the stay (evaluation and treatment score); and readiness for discharge (discharge score). The associations between age and quality of care scores were analysed using linear regression models. RESULTS: Charts of 371 patients were reviewed. Mean age was 75.7 (+/-11.1) years and 52% were men. There was no relationship between age and admission or readiness for discharge scores. The evaluation and treatment score decreased with age: compared with patients less than 70 years old, the score was lower by -2.6% (95% CI: -7.1 to 1.9) for patients aged 70 to 79, by -8.7% (95% CI: -13.0 to -4.3) for patients aged 80 to 89, and by -19.0% (95% CI: -26.6 to -11.5) for patients aged 90 and over. After adjustment for possible confounders, this relationship was not significantly modified. CONCLUSIONS: In patients hospitalized for congestive heart failure, older age was not associated with lower quality of care scores except for evaluation and treatment. Whether this is detrimental to elderly patients remains to be evaluated.     

Valsartan in the treatment of heart failure or left ventricular dysfunction after myocardial infarction

The physiological role of the renin angiotensin aldosterone system (RAAS) is to maintain the integrity of the cardiovascular system. The effect of angiotensin II is mediated via the angiotensin type I receptor (AT1 ) resulting in vasoconstriction, sodium retention and myocyte growth changes. This causes myocardial remodeling which eventually leads to left ventricular hypertrophy, dilation and dysfunction. Inhibition of the RAAS with angiotensin converting enzyme (ACE) inhibitors after acute myocardial infarction has been shown to reduce cardiovascular morbidity and mortality. Angiotensin receptor blockers (ARBs) specifically inhibit the AT1 receptor. It has not been known until the performance of the VALIANT (valsartan in acute myocardial infarction trial) whether blockade of the angiotensin receptor with an ARB or combination of an ACE inhibitor and ARB leads to similar outcomes as an ACE inhibitor. The VALIANT trial demonstrated equal efficacy and non-inferiority of the ARB valsartan 160 mg bid compared with captopril 50 mg tds, when administered to high risk patients with left ventricular dysfunction or heart failure in the immediate post myocardial infarction period. The combination therapy showed no incremental benefit over ACE inhibition or an ARB alone and resulted in increased adverse effects. This review examines the role of valsartan in left ventricular dysfunction post myocardial infarction. We also discuss pharmacokinetics, dosing, side effects, and usage in the elderly.     

慢性心力衰竭治疗质量指标体系的建立

目的 建立一套适合中国慢性心力衰竭治疗质量评价的指标体系,为下一步慢性心衰治疗质量评价提供量化工具.方法 检索PubMed、EMBASE等数据库,同时参考〈慢性心力衰竭诊断治疗指南〉筛选出候选指标.选择来自北京、上海、哈尔滨的15名专家组成专家组.应用德尔菲法咨询专家意见,根据专家打分的均数和选择率确定最终的指标体系.纳入标准为：均数≥3.5,选择率≥50.0%.结果 发放专家咨询表15份,专家积极系数为100%,每份均符合要求.经过三轮Delphi,由最初52个候选指标筛选出22个指标,构成慢性心衰治疗质量评价的指标体系,包括2个结构指标,18个过程指标（15个院内指标,3个出院指标）,2个结局指标.指标体系中,均数〉4分的有12个,选择率≥80.0%的9个.利尿剂的均数和选择率最大,分别为4.7和100%;院内感染率≤7%的均数和选择率最小,分别为3.5和53.3%.指标均数的范围为3.5~4.7,选择率的范围为53.3%~100.0%.结论 本研究建立的慢性心力衰竭治疗质量评价指标体系与国外相关组织建立的稍有不同,符合我国国情,能全面客观的评价慢性心衰的治疗质量,发现其中的不足,以促进我国慢性心衰治疗质量的改善.     

不同心脏疾病所致慢性收缩性心力衰竭患者预后的比较

目的 探讨病因对慢性收缩性心力衰竭(心衰)患者预后影响.方法 回顾性分析湖北地区16 681例心衰住院患者临床资料,所有患者电话随访.Cox比例风险模型评价不同病因患者预后差异并构建Kaplan-Meier曲线.Cox生存分析评价心衰患者预后危险因素.多元logistic回归分析构建ROC曲线.结果 (1)随访3(...     

Hospital staffing, organization, and quality of care: cross-national findings.

OBJECTIVE: To examine the effects of nurse staffing and organizational support for nursing care on nurses' dissatisfaction with their jobs, nurse burnout, and nurse reports of quality of patient care in an international sample of hospitals. DESIGN: Multisite cross-sectional survey. SETTING: Adult acute-care hospitals in the United States (Pennsylvania), Canada (Ontario and British Columbia), England, and Scotland. STUDY PARTICIPANTS: 10 319 nurses working on medical and surgical units in 303 hospitals across the five jurisdictions. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Nurse job dissatisfaction, burnout, and nurse-rated quality of care. RESULTS: Dissatisfaction, burnout, and concerns about quality of care were common among hospital nurses in all five sites. Organizational/managerial support for nursing had a pronounced effect on nurse dissatisfaction and burnout, and both organizational support for nursing and nurse staffing were directly, and independently, related to nurse-assessed quality of care. Multivariate results imply that nurse reports of low quality care were three times as likely in hospitals with low staffing and support for nurses as in hospitals with high staffing and support. CONCLUSION: Adequate nurse staffing and organizational/managerial support for nursing are key to improving the quality of patient care, to diminishing nurse job dissatisfaction and burnout and, ultimately, to improving the nurse retention problem in hospital settings.     

高血压左室肥厚伴左心衰竭心脏彩超分析

目的对高血压左室肥厚伴左心衰竭患者的心脏彩超特征进行分析,为今后的临床诊断与治疗工作提供参考。方法抽取2011年11月—2013年11月收治的临床确诊高血压左室肥厚伴左心衰竭患者76例作为高血压组,同期心功能正常者60例作为正常组,对以上统计的两组研究对象展开心脏彩超检查,并对这两组研究对象的检查结果进行对比分析。计量资料采用t检验,计数资料采用χ2检验,P0.05为差异有统计学意义。结果高血压组患者的LAD、LVDd、E/Ea[(50.43±10.17)、(77.74±10.98)mm、14.43±3.71、(55.48±8.97)%]均较心功能正常组[(36.44±8.79)、(45.76±8.76)mm、7.06±2.01]显著升高(均P0.05),而LVEF值[(55.48±8.97)%]则较心功能正常组[(66.75±9.08)%]显著降低(P0.05)。随着心功能分级不断升高,患者的LAD、LVDd、E、Ea水平逐渐升高(P0.05),LVEF水平逐渐降低(P0.05)。结论经心脏彩超可对高血压左室肥厚伴左心衰竭进行准确的诊断,具有可行性,值得关注。     

气温变化与慢性收缩性心力衰竭住院患者数量的相关分析

目的探讨气温变化对慢性收缩性心力衰竭(CSHF)住院患者例数的影响。方法回顾性调查湖北地区12家医院2000年1月1日至2010年5月31日期间住院心衰患者48 964例。单因素和多因素logistic回归分析不同月份患者人院风险。结果(1)与月平均住院人数(391.71人次用)相比，1-12月分别增加18.71 %,13.84%, -21.90%, -34.62%, -21.97%, -3.81 %, -2.04%,10.13%.-17.13%,-0.85%,21.54%和42.70% o ( 2)女性患者1,2和12月与8月相比住院风险的差异无统计学意义「OR值及其95%CI分别为1.09 ( 0.96~1.23),0.98(0.84~1.10)和0.96 ( 0.84~1.08),P值均>0.05 ]，而男性患者同期相比住院风险显著降低〔OR值及其95%CI分别为0.61(0.54~0.69),0.80 ( 0.68~0.92)和0.73 ( 0.64~0.83),P值均<0.01]0(3)气温降低对冠心病、高血压性心脏病和风湿性瓣膜病的CSHF患者，其人院风险更大，而扩张型心肌病患者则相反。(4)气温变化对不同职业患者人院风险存在差异。结论CSHF患者人院风险与气温变化密切相关。与年均气温相差越大的月份，患者人院风险相对越高，且入院风险的影响在不同性别、病因和职业存在差异。     

Assessment of the quality of breast cancer care: a single institutional study from Saudi Arabia.

OBJECTIVE: To evaluate the quality of operable breast cancer care in a tertiary care institution. DESIGN: A retrospective analysis of all breast cancer patients seen in our institution between 1995 and 2000. Data were abstracted from the charts of these patients. Indicators were based on an international consensus conference and other publications. SETTING: A tertiary care health care institution. MAIN MEASURES: We evaluated the charts and calculated the percentage for which the internationally accepted quality care indicators were followed during the continuum of care. We also reviewed the histopathological reports to evaluate conformation with the accepted indicators. RESULTS: Charts of 75 patients (four exclusions, three metastatic, and one male), diagnosed to have breast cancer during the study period were reviewed. Only 28 (37%) patients had triple assessment before a definitive surgical procedure. Pre-operative staging including a CT and bone scan was performed in 58 (77.3%). Among the 50 patients who had definite surgical intervention, the majority had mastectomy (44/50, 88%) whereas axillary dissection was performed in 46 (46/50, 92%). Estrogen and progesterone receptor status was reported in only four (4/50, 8%) and the exact tumor size in 24 (24/50, 48%) of the histopathological reports. Adjuvant chemotherapy was used in accordance with the international standards but radiotherapy was under-utilized. CONCLUSION: Our study demonstrated that the quality of breast cancer care in this institution was below the accepted international standards. This study may be used to make interventions for improvement of quality in similar institutions all over the kingdom.     

Association between cardiac,renal, and hepatic biomarkers and outcomes in patients with acute heart failure

Objectives: Myocardial injury, worsening renal function, and hepatic impairment are independent risk factors for poor patient acute heart failure (AHF) outcomes. Biomarkers of organ damage may be useful in identifying patients at risk for poor outcomes. The objective of this analysis was to assess the relationship between abnormal AHF biomarkers and outcomes in AHF patients.

Methods: AHF admissions (N = 104,794) data from the Cerner Health Facts® inpatient database were analyzed retrospectively. Multivariate predictive models determined the impact of biomarkers on mortality, readmission, length of stay (LOS), and cost from index admission through 180 days post discharge. Thirty and 60 day time windows are reported but 180 day results were consistent with 60 day outcomes. Biomarkers evaluated were aspartate transaminase (AST), estimated glomerular filtration rate (eGFR), high sensitivity cardiac troponin, bilirubin, alanine transaminase (ALT), sodium, high sensitivity C-reactive protein (hs-CRP), uric acid, B-type natriuretic peptide (BNP), NT-ProBNP, blood urea nitrogen (BUN), serum creatinine (SCr), and hemoglobin.

Results: All biomarkers evaluated except hs-CRP, uric acid, and NT-ProBNP were significant (p < 0.0001) predictors of mortality at all timepoints; non-significance for these 3 biomarkers is likely due to low patient counts (1%–2%). Odds ratios for significant biomarkers of mortality ranged from 1.168–2.076 at index admission, 1.205–1.946 at 30 days post-discharge, and 1.233–1.991 at 60 days post-discharge. AST, eGFR, troponin, ALT, BNP, BUN, SCr, and hemoglobin were significant (p < 0.0001) predictors of readmission risk at all timepoints. AST, eGFR, troponin, bilirubin, BUN, SCr, and hemoglobin were significant (p < 0.0001) predictors of cumulative LOS at all timepoints. AST, eGFR, troponin, ALT, sodium, BUN, and hemoglogin were significant (p < 0.0001) cost predictors at 30 and 60 days post-discharge.

Conclusions: Renal function measures were associated with outcomes in patients hospitalized for AHF. Increased vigilance of renal biomarkers may be warranted to assess risk and promote proactive clinical management to improve outcomes.     

Functional status outcomes for assessment of quality in long-term care.

OBJECTIVE: Although decline in functional status has been recommended as a quality indicator in long-term care, studies examining its use provide no consensus on which definition of functional status outcome is the most appropriate to use for quality assessment. We examined whether different definitions of decline in functional status affect judgments of quality of care provided in Department of Veterans Affairs (VA) long-term care facilities. METHODS: Six measures of functional status outcome that are prominent in the literature were considered. The sample consisted of 15 409 individuals who resided in VA long-term care facilities at any time from 4/1/95 to 10/1/95. Activities of daily living variables were used to generate measures of functional status. Differences between residents' baseline and semi-annual assessments were considered and facility performance using the various definitions of functional status were described. RESULTS: The percentage of residents seen as declining in functional status ranged from 7.7% to 31.5%, depending upon the definition applied. The definition of functional status also affected rankings, z-scores, and 'outlier' status for facilities. CONCLUSION: Judgments of facility performance are sensitive to how outcome measures are defined. Careful selection of an appropriate definition of functional status outcome is needed when assessing quality in long-term care.     

心力衰竭患者治疗效果标准化院内死亡率评价

目的 基于风险调整思想计算标准化院内死亡率, 合理评价医院心力衰竭的治疗质量。方法 收集黑龙江省20家三甲医院2009年1月—2010年10月入院的1 862例心力衰竭患者病历资料, 采用两水平logistic回归模型构建心力衰竭患者院内死亡的风险调整模型, 利用ROC曲线下面积(AUC)评价模型的拟合优度。结果1 862 例心力衰竭患者中, 87例患者在住院期间死亡, 院内死亡率为4.67%。不同特征心力衰竭患者院内死亡率比较, 不同民族、入院时病情、住院天数、心率及是否患呼吸系统疾病、肾脏疾病、心肌病、失盐低钠综合征心力衰竭患者院内死亡率差异均有统计学意义(P<0.05);两水平logistic回归分析结果显示, 年龄较大、有疾病史及患肾脏疾病和失盐低钠综合征的心力衰竭患者院内死亡风险较大, 住院天数较长、入院时病情较轻和患高血压的心力衰竭患者院内死亡风险较小;心力衰竭患者院内死亡风险调整模型的ROC曲线, AUC为0.80, 95%CI=0.75~0.85, P<0.001;风险调整前, 院内死亡率在医院间的变异范围为0~12.82%, 风险调整后, 医院的排序发生变化, 院内死亡率在医院间的变异范围为2.59%~7.62%。结论 风险调整后, 院内死亡率在医院间的变异减小, 粗院内死亡率和标准化院内死亡率对医院的排序不一致, 调整患者风险因素的标准化院内死亡率能合理地评价医院的治疗质量。     

急性左心衰136临床分析

目的探讨急性左心衰的诱因、临床特征、早期诊断及正确的治疗对策。方法对136例急性左心衰患者进行回顾性分析。结果急性左心衰在老年人中多见,在急性左心衰的诱因中感染多见,其次为急性血压升高、排便用力及快速心律失常。病因以冠心病多见,高血压心脏病次之。结论及时发现、诊断、治疗并针对病因、消除诱因,可减少病死率。提示对高血压患者平时应尽量控制血压,冠心病应控制心绞痛,及早发现急性左心衰的先兆,可减少病死率。     

无创呼吸机在急性左心衰患者治疗中的应用

目的探讨和分析无创呼吸机在急性左心衰竭患者中的临床治疗效果。方法选取2011年9月—2013年5月,在我院急诊抢救治疗的急性左心衰竭患者共140例作为研究对象,按随机原则,分成观察组和对照组各70例,对照组患者给予传统的治疗,观察组患者在对照组的基础上,给予无创呼吸机治疗,治疗一周后,观察两组患者的临床治疗效果和再住院率、心脏时间发生率以及不良反应等并发症的发生状况。结果经过一周治疗,观察组患者与对照组患者的总有效率分别为88.6%和68.6%,该两组患者的总有效率对比,存在显著的差异（t=5.507,P〈0.01）,具有统计学意义。经治疗后,观察组患者的再住院率、心脏事件发生率和分别为25.7%和2.9%,明显低于对照组患者（48.6%、18.6%）,两组再住院率、心脏事件发生率对比具有明显的差异（P〈0.05）,存在统计学意义。观察组与对照的患者的不良反应发生率分别为8.6%和15.7%,该两组的不良反应发生率对比,没有显著的差异（χ2=2.307,P〉0.05）,不存在统计学意义。结论对于急性左心衰患者,运用无创呼吸机通气治疗,有着安全有效的优点,能够显著提高患者的临床治疗效果,并降低并发症的发生率,值得临床推广。     

慢性收缩性心力衰竭患者血尿酸浓度改变及其与氧化应激的关系研究

目的 研究慢性收缩性心力衰竭(CSHF)患者血尿酸(UA)浓度改变与心功能及谷胱甘肽抗氧化系统的关系.方法 选择2006年6月至2007年3月109例患者,根据有无器质性心脏病及心功能情况分为CSHF组81例,对照组28例,CSHF组又按纽约心脏病协会(NYHA)心功能分级分为心功能Ⅱ级组28例,心功能Ⅲ级组28例,心功能Ⅳ级组25例.所有患者均于入院第2天采空腹静脉血,应用酶循环法测定血浆还原型谷胱甘肽(GSH)、氧化型谷胱甘肽(GSSG)浓度,并利用Nernst公式计算氧化还原电位Eh值.结果 CSHF组患者血UA浓度[(499.09±168.04)μmol/L]较对照组[(310.54±99.92)μmol/L]明显升高(P<0.01),且随着心功能分级的增加而升高,与LVEF呈负相关(r=-0.247,P=0.026),与左室舒张末期内径(LVEDD)呈正相关(r=0.266,P=0.016).血UA浓度与血浆GSH浓度呈负相关(r=-0.328,P=0.003),与血浆GSSG浓度呈正相关(r=0.244,P=0.028),与Eh值呈正相关(r=0.309,P=0.005).结论 CHF时血UA浓度升高,且与心功能分级、LVEF、LVEDD存在相关性,可作为反映收缩性心功能不全患者心功能状态的补充指标;血UA浓度还与血浆GSH浓度呈负相关、与血浆GSSG浓度及Eh值呈正相关,结合CSHF时UA的代谢途径,提示UA有可能作为氧化应激的指标.     

慢性收缩性心力衰竭患者药物治疗情况调查及相关因素分析

目的 分析湖北省慢性收缩性心力衰竭(心衰)患者药物治疗分布及其影响因素.方法 回顾性调查和分析2000-2010年湖北省8市12家三级甲等医院心衰住院患者资料,根据年龄、性别和随访结果分组,分析不同组间药物治疗种类和药费的分布差异.对药物治疗年费用进行log10对数转换.结果 (1)共16 681例心衰患者纳入研究,随访期间有6453例死亡.死亡组药物治疗年费用低于存活组(3.19±0.65vs.3.32±0.57,P＜0.01).(2)血管紧张素受体阻滞剂使用率随年龄增加而增加;而地高辛、利尿剂、B受体阻滞剂、血管紧张素转化酶抑制剂使用率随年龄增加呈倒“U”形分布.不同年龄组药物治疗存在性别差异.(3)随着患者年龄增加药物治疗费用有增加趋势(＜30、30～、40～、50 ～、60～和70 ～ 79岁组分别为2.96±0.70、3.09±0.62、3.15±0.58、3.30±0.59、3.25±0.58和3.35±0.60,P＜0.01),而年龄≥80岁组减低至50～岁组水平.男性患者药物治疗费的分布与全部患者水平相似,而女性患者在＜30、30～和40～岁组间无差异,在其他年龄组的分布与全部患者水平相似.结论 湖北省心衰患者药物治疗有待改善,药物治疗受年龄、性别影响,其中女性患者药物治疗情况较男性差.