2001-2011年中国急性心肌梗死住院患者肾素—血管紧张素—醛固酮系统抑制剂应用的质量评价研究

发布时间：2018-06-07 02:47

本文选题：肾素-血管紧张素-醛固酮系统抑制剂 + 急性心肌梗死　；参考：《北京协和医学院》2017年博士论文

【摘要】：背景:心血管疾病是导致我国死亡的首要原因。其中,急性心肌梗死(AMI)是心血管疾病的急重症,发病率高、致残率高、病死率高,医疗花费高,严重威胁民众健康;且目前发病率仍呈上升趋势,疾病负担日益沉重。在此背景下,保证现有AMI诊疗服务的规范性和高质量至关重要。除了及时的再灌注治疗,规范使用有循证证据、能够改善预后的药物也是AMI的重要治疗手段。肾素-血管紧张素-醛固酮系统(RAAS)抑制剂是治疗AMI的一类重要药物,包括肾素血管紧张素转换酶抑制剂(ACEI)、肾素血管紧张素受体抑制剂(ARB)和醛固酮受体拮抗剂(AA)。大量临床试验表明,适宜人群使用上述药物可显著改善预后,国内外AMI临床指南均推荐使用。其用药需首先测量左室射血分数(LVEF),以评价是否具备临床指征。此外,在无指征或有禁忌症的人群中使用上述药物,不仅不会带来获益,反有可能将患者暴露于额外风险;除此以外,我国既往无数据报道AMI患者中RAAS抑制剂的使用情况,无从了解其使用的规范性。目的:根据患者用药指征和禁忌症,分别评价中国2001-2011年间AMI患者住院期间ACEI/ARB和安体舒通(我国唯一的AA类药物)的使用变化趋势,以及LVEF测量的变化趋势;分别探讨患者和医院层面影响应用的因素;分析不同地区、不同医院间的应用差异。方法:利用冠心病医疗结果评价和临床转化研究-回顾性AMI研究,基于具有全国代表性的AMI抽样队列(2001年、2006年、2011年),分别确定ACEI/ARB、安体舒通和LVEF测量的样本人群。首先,总体描述了 ACEI/ARB、安体舒通和LVEF测量的应用情况,使用广义估计方程的多水平logistic回归模型分析影响各自应用的患者因素;继而在医院水平,运用随机截距风险模型计算各地区、各医院经患者因素校正后的风险标化未使用率(RSNUR)及95%置信区间(CI),根据其95%CI与全国均值的关系,将医院分为三类以评价医院表现(较差:95%CI下限高于全国均值;较好:95%CI上限低于全国均值;符合预期:95%CI覆盖全国均值),并使用多水平线性回归模型分析医院层面影响RSNUR的因素。结果:2001-2011年,ACEI/ARB在符合中国指南I类推荐的患者中使用率先升后降(2001 年 62.0%,2006 年 71.4%,2011 年 67.6%,趋势 P 值=0.01);在有禁忌症的患者中使用率先降后升(分别为40.1%,34.5%和50.4%,趋势P值0.001)。全国ACEI/ARB平均RSNUR为33.6%(标准差14.1),各医院波动范围为4.5%-74.1%。37.2%的医院RSNUR95%CI下限高于全国平均值,表现较差;三个区域中,中部地区医院表现较好医院所占比例最高(64.7%),同时表现较差医院所占比例最低(32.4%)。医院特征对ACEI/ARB的RSNUR无明显影响。2001-2011年,未接受安体舒通用药指征评估(LVEF测量)的患者比例下降(从2001年的66.9%降至2011年的32.8%)。十年间,有指征人群中安体舒通的使用率显著提高(28.6%至72.4%,趋势P值0.001),然而,禁忌症、无指征和指征不明人群中安体舒通使用率同样升高(禁忌症人群11.4%至27.5%,无指征人群27.5%至38.3%,指征不详人群21.3%至35.1%;趋势P值均0.01)。四组人群中,入院时合并心力衰竭的患者均有更大概率接受到安体舒通治疗。由于安体舒通各组人群样本量较小,统计学把握度不够,故未分析医院之间差异。2001、2006、2011 年,AMI 患者住院期间 LVEF 测量率分别为 23.2%,46.9%,68.1%,呈上升趋势(趋势P值0.001)。女性患者、有冠心病病史的患者、入院时合并急性脑卒中者、心率90次/份者更不容易接受到LVEF测量。全国LVEF平均RSNUR为38.4%(标准差16.9),各医院RSNUR从8.9%到78.4%不等。48.3%的医院RSNUR高于全国平均水平,表现欠佳。中部地区医院表现较差医院所占比例最高(56.3%),而表现较好医院所占比例最低(31.3%)。结论:2001-2011年间,我国安体舒通的合理使用率和LVEF测量率有显著提高,而ACEI/ARB使用无明显改善;ACEI/ARB和安体舒通在禁忌症人群中的不合理使用令人担忧。不同医院在ACEI/ARB使用和LVEF测量上存在明显差异,提示诊疗均质性欠佳。三者应用均仍存在较大改善空间。未来研究应进一步探讨出现上述情况的原因,为医疗卫生机构及卫生行政主管部门制定针对性的质量改善措施提供科学依据,各部门共同努力,优化RAAS抑制剂在AMI患者中的应用。
[Abstract]:Background: cardiovascular disease is the leading cause of death in China. Among them, acute myocardial infarction (AMI) is a serious disease of cardiovascular disease, high incidence, high morbidity, high mortality, high medical cost and serious threat to the health of the people. And the current incidence is still rising, and the burden of disease is increasingly heavy. In this context, we guarantee the existing AMI diagnosis and treatment. The normalization and high quality of service are essential. In addition to timely reperfusion therapy, the use of evidence-based evidence is used to improve the prognosis. The renin angiotensin aldosterone system (RAAS) inhibitor is an important class of drugs for the treatment of AMI, including the renin angiotensin converting enzyme inhibitor (ACEI). The renin angiotensin receptor inhibitor (ARB) and aldosterone receptor antagonist (AA). A large number of clinical trials have shown that the use of these drugs can significantly improve the prognosis. The AMI clinical guidelines both at home and abroad are recommended. The use of the left ventricular ejection fraction (LVEF) should be first measured to evaluate the clinical indications. The use of these drugs in contraindication people will not only bring benefits, but may expose the patients to additional risks; in addition, there is no previous data reporting on the use of RAAS inhibitors in AMI patients, and the standardization of their use is not understood. Objective: To evaluate China for 2001-2011 years according to the indications and contraindications of the patients. The change trend of the use of ACEI/ARB and spironolactone (the only AA class in our country) during the hospitalization of AMI patients, and the trend of the changes in the LVEF measurement; the factors affecting the application of the patients and the hospital level respectively; the analysis of the differences in the application between different regions and different hospitals. Methods: the evaluation of the medical results of coronary heart disease and the study of clinical transformation. AMI studies, based on a national representative AMI sampling queue (2001, 2006, 2011), determine the sample population of ACEI/ARB, spironolactone and LVEF respectively. First, the overall description of the application of ACEI/ARB, spironolonet and LVEF measurements, and the use of the multilevel logistic regression model of the generalized estimation equation to analyze their respective effects In the hospital level, the hospital level was used to calculate the risk standard unuse rate (RSNUR) and 95% confidence interval (CI) of each hospital, and the hospital was divided into three categories according to the relationship between the 95%CI and the national average. The lower 95%CI lower limit was higher than the national average; Good: the 95%CI upper limit is lower than the national average; it is consistent with expectations: 95%CI covers the national average) and uses a multilevel linear regression model to analyze the factors affecting the RSNUR at the hospital level. Results: 2001-2011 years, ACEI/ARB used the first ascending descending (2001 62%, 2006 71.4%, 2011 67.6%, trend P value =0) in compliance with the Chinese guide I recommendations. .01); in the patients with contraindications, the first descending rise (40.1%, 34.5% and 50.4%, and the trend P value 0.001). The national ACEI/ARB average RSNUR was 33.6% (the standard deviation 14.1), and the hospital's fluctuation range of 4.5%-74.1%.37.2% was higher than the national average, and the performance was poor; in three regions, the hospitals in the central region showed better medical treatment. The proportion of the hospital was the highest (64.7%), and the proportion of poor hospitals was the lowest (32.4%). The hospital characteristics had no obvious effect on the RSNUR of ACEI/ARB for.2001-2011 years, and the proportion of patients who did not accept the use of LVEF measurements (from 66.9% in 2001 to 32.8% in 2011). The use rate was significantly increased (28.6% to 72.4%, trend P value 0.001). However, contraindications, unspecified and unidentified people also increased the use of spironolactone (11.4% to 27.5% in contraindications, 27.5% to 38.3% in non indications, 21.3% to 35.1% in unknown population, 0.01 in the trend P value). In group four, patients with heart failure were all admitted to hospital. There was a greater probability of receiving the treatment of spironolactone. Because of the small sample size and lack of statistical assurance in the groups of the groups, the LVEF measurement rate of AMI patients was 23.2%, 46.9%, 68.1%, respectively, during the.200120062011 years of hospitalization. In patients with acute stroke at admission, the heart rate 90 times per person was less likely to be measured by LVEF. The national LVEF average RSNUR was 38.4% (standard deviation 16.9), and the RSNUR of each hospital RSNUR from 8.9% to 78.4%.48.3% was higher than the national average, and the performance was not good. The proportion of poor hospitals in the medical hospital of the central region was the highest (56.3%), and the performance of the hospital was the highest (56.3%). The proportion of better hospitals is the lowest (31.3%). Conclusion: in 2001-2011 years, the rational use rate and LVEF measurement rate of spironolactone in China have been significantly improved, but the use of ACEI/ARB is not obviously improved, and the irrational use of ACEI/ARB and spironolactone in contraindication people is worrying. There is a significant difference between the use of ACEI/ARB and the measurement of LVEF in different hospitals. In the future research should further explore the reasons for the above situation, and provide the scientific basis for the medical institutions and the health administration departments to formulate the targeted quality improvement measures. All departments work together to optimize the RAAS inhibitors in the AMI patients. Use.
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R542.22

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