JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY | 卷:60 |
Hospital Patterns of Use of Positive Inotropic Agents in Patients With Heart Failure | |
Article | |
Partovian, Chohreh1,2  Gleim, Scott R.1  Mody, Purav S.1,2  Li, Shu-Xia2  Wang, Haiyan2  Strait, Kelly M.2  Allen, Larry A.3,4  Lagu, Tara5,6,7  Normand, Sharon-Lise T.8,9  Krumholz, Harlan M.1,2,10,11  | |
[1] Yale Univ, Sch Med, Sect Cardiovasc Med, Dept Internal Med, New Haven, CT 06510 USA | |
[2] Yale New Haven Med Ctr, Ctr Outcomes Res & Evaluat, New Haven, CT 06504 USA | |
[3] Univ Colorado, Anschutz Med Ctr, Colorado Cardiovasc Outcomes Res Consortium, Aurora, CO USA | |
[4] Univ Colorado, Anschutz Med Ctr, Sect Adv Heart Failure & Transplantat, Div Cardiol, Aurora, CO USA | |
[5] Tufts Univ, Sch Med, Dept Med, Boston, MA 02111 USA | |
[6] Baystate Med Ctr, Ctr Qual Care Res, Springfield, MA USA | |
[7] Baystate Med Ctr, Div Gen Med & Geriatr, Springfield, MA USA | |
[8] Harvard Univ, Sch Med, Dept Hlth Care Policy, Boston, MA 02115 USA | |
[9] Harvard Univ, Sch Publ Hlth, Dept Biostat, Boston, MA 02115 USA | |
[10] Yale Univ, Sch Med, Robert Wood Johnson Clin Scholars Program, Dept Internal Med, New Haven, CT 06510 USA | |
[11] Yale Univ, Sch Publ Hlth, Sect Hlth Policy & Adm, New Haven, CT 06510 USA | |
关键词: heart failure; in-hospital mortality; inotrope use; variation in care; | |
DOI : 10.1016/j.jacc.2012.07.011 | |
来源: Elsevier | |
【 摘 要 】
Objectives This study sought to determine hospital variation in the use of positive inotropic agents in patients with heart failure. Background Clinical guidelines recommend targeted use of positive inotropic agents in highly selected patients, but data are limited and the recommendations are not specific. Methods We analyzed data from 376 hospitals including 189,948 hospitalizations for heart failure from 2009 through 2010. We used hierarchical logistic regression models to estimate hospital-level risk-standardized rates of inotrope use and risk-standardized in-hospital mortality rates. Results The risk-standardized rates of inotrope use ranged across hospitals from 0.9% to 44.6% (median: 6.3%, inter-quartile range: 4.3% to 9.2%). We identified various hospital patterns based on the type of agents: dobutamine-predominant (29% of hospitals), dopamine-predominant (25%), milrinone-predominant (1%), mixed dobutamine and dopamine pattern (32%), and mixed pattern including all 3 agents (13%). When studying the factors associated with interhospital variation, the best model performance was with the hierarchical generalized linear models that adjusted for patient case mix and an individual hospital effect (receiver operating characteristic curves from 0.77 to 0.88). The intraclass correlation coefficients of the hierarchical generalized linear models (0.113 for any inotrope) indicated that a noteworthy proportion of the observed variation was related to an individual institutional effect. Hospital rates or patterns of use were not associated with differences in length of stay or risk-standardized mortality rates. Conclusions We found marked differences in the use of inotropic agents for heart failure patients among a diverse group of hospitals. This variability, occurring in the context of little clinical evidence, indicates an urgent need to define the appropriate use of these medications. (J Am Coll Cardiol 2012;60:1402-9) (C) 2012 by the American College of Cardiology Foundation
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