2001—2011年我国农村地区医院急性心肌梗死患者院内他汀类药物的应用
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摘要
目的评价2001—2011年我国农村地区医院急性心肌梗死(AMI)患者院内他汀类药物应用的变化趋势,并探讨其影响因素。方法采用两阶段随机抽样方法,即简单随机抽样抽取农村地区医院,系统随机抽样从抽中医院中抽取2001、2006和2011年AMI患者住院病历。提取病历中临床信息,计算他汀类药物的使用率和变化趋势,Cochran-Armitage检验使用变化趋势,多水平多因素logistic回归模型分析影响因素。结果抽取105家医院,99家参加研究。抽取2001、2006和2011年AMI住院患者病历7111份,获得6979份(98.1%),入选5664例适宜使用他汀类药物的患者。他汀类药物使用率从2001年的12.8%上升至2006年的60.4%及2011年的84.3%(趋势P值<0.001)。2001、2006和2011年使用他汀类药物的人群中,中等及以上强度他汀类药物的使用率分别是15. 3%、55. 7%和78. 8%(趋势P值<0.001)。不同低密度脂蛋白胆固醇(LDL-C)水平及年份之间使用率差异逐渐缩小。降脂效能高的他汀类药物使用比例逐渐升高。2011年,高血压、入院时胸痛、LDL-C水平都会影响他汀类药物使用。未检测LDL-C的患者获得他汀类药物治疗的可能性相对较小,LDL-C≥1.8 mmol·L~(-1)的患者更易接受治疗。结论 2001—2011年,我国农村地区医院AMI患者院内他汀类药物可及性和应用规范性大幅提高,指南对他汀类药物的推荐在实践中快速普及,但规范使用仍存在改善空间。医疗机构及管理部门需要制定有针对性的改善措施,优化他汀类药物的应用。
Objective To determine current usage rates and temporal trends in statin therapy,and to analyze factors associated with the lack of statin therapy among patients hospitalized with acute myocardial infarction( AMI) in rural China hospitals from the year 2001 to 2011. Methods A representative sample of patients in rural China admitted to hospital for AMI was created from a two-stage random sampling. A simple random-sampling procedure was used to identify participating hospitals. Patients admitted to each participating hospitals for AMI in 2001,2006,and 2011 were selected using a systematic sampling approach. Clinical information was obtained via central medical record abstraction for each patient,and then in-hospital statin use was analyzed. A multilevel logistic regression models with use of generalized estimating equations were performed to explore associated factors of the use of statin therapy. Results Among 105 sampled rural hospitals,99 hospitals participated.Totally,5664 patients were identified eligible for statin therapy to determine rates of statin use and the intensity of statin therapy.Rates of statin use among hospitalized patients with AMI in rural China increased from 12.8% in 2001 to 60.4% in 2006,and84.3% in 2011( P<0.001 for trend). Among the patients treated with statin,those receiving moderate and above intensity statin therapy increased from 15.3% in 2001 to 55.7% in 2006,and 78.8% in 2011( P<0.001 for trend). The variation in statin use in different density lipoprotein cholesterol( LDL-C) group and years decreased overtime. And in the multivariable model,several patient factors were associated with statin therapy. Patients without LDL-C measured during the hospitalization were significantly less likely to receive statin therapy. Patients with hypertension or chest pain or high level of LDL-C were associated with high possibility to receive statin therapy. Conclusion From the year 2001 to 2011 in rural China,the use of statin therapy has dramatically increased. However,gaps still persist among guideline and clinical practice. Initiatives promoting the use of statin therapy would support further improvements in practice.
Objective To determine current usage rates and temporal trends in statin therapy,and to analyze factors associated with the lack of statin therapy among patients hospitalized with acute myocardial infarction( AMI) in rural China hospitals from the year 2001 to 2011. Methods A representative sample of patients in rural China admitted to hospital for AMI was created from a two-stage random sampling. A simple random-sampling procedure was used to identify participating hospitals. Patients admitted to each participating hospitals for AMI in 2001,2006,and 2011 were selected using a systematic sampling approach. Clinical information was obtained via central medical record abstraction for each patient,and then in-hospital statin use was analyzed. A multilevel logistic regression models with use of generalized estimating equations were performed to explore associated factors of the use of statin therapy. Results Among 105 sampled rural hospitals,99 hospitals participated.Totally,5664 patients were identified eligible for statin therapy to determine rates of statin use and the intensity of statin therapy.Rates of statin use among hospitalized patients with AMI in rural China increased from 12.8% in 2001 to 60.4% in 2006,and84.3% in 2011( P<0.001 for trend). Among the patients treated with statin,those receiving moderate and above intensity statin therapy increased from 15.3% in 2001 to 55.7% in 2006,and 78.8% in 2011( P<0.001 for trend). The variation in statin use in different density lipoprotein cholesterol( LDL-C) group and years decreased overtime. And in the multivariable model,several patient factors were associated with statin therapy. Patients without LDL-C measured during the hospitalization were significantly less likely to receive statin therapy. Patients with hypertension or chest pain or high level of LDL-C were associated with high possibility to receive statin therapy. Conclusion From the year 2001 to 2011 in rural China,the use of statin therapy has dramatically increased. However,gaps still persist among guideline and clinical practice. Initiatives promoting the use of statin therapy would support further improvements in practice.
引文
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[14]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.不稳定性心绞痛和非ST段抬高心肌梗死诊断与治疗指南[J].中华心血管病杂志,2007,35(4):295-304.
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[16]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.急性ST段抬高型心肌梗死诊断和治疗指南[J].中华心血管病杂志,2015,43(5):380-393.
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[18]STEG P G,JAMES S K,ATAR D,et al.ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation[J].Eur Heart J,2012,33(20):2569-2619.
[19]DHARMARAJAN K,LI J,LI X,et al.The China PatientCentered Evaluative Assessment of Cardiac Events(China PEACE)retrospective study of acute myocardial infarction:study design[J].Circ Cardiovasc Qual Outcomes,2013,6(6):732-740.
[20]ANTMAN E M,ANBE D T,ARMSTRONG P W,et al,ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary.Areport of the American college of cardiology/American heart association task force on practice guidelines(Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction)[J].J Am Coll Cardiol,2004,44(3):671-719.
[21]李晶,金泽宁,陈韵岱,等.急性心肌梗死治疗指南对我国住院患者治疗及预后的影响[J].中国危重病急救医学,2010,22(11):649-655.
[22]CHENG T M.Early results of China's historic health reforms:the view from minister Chen Zhu.Interview by TsungMei Cheng[J].Health Aff(Millwood),2012,31(11):2536-2544.
[23]CHEN Y,JIANG L,ZHANG Q,et al.Doctor-reported hospital management of acute coronary syndrome in China:a nationwide survey of 1029 hospitals in 30 provinces[J].World J Card Dis,2012,2(3):168-176.
[24]ZHANG L,LI J,LI X,et al.National Assessment of statin therapy in patients hospitalized with acute myocardial infarction:insight from China PEACE-retrospective AMIstudy,2001,2006,2011[J].PLoS One,2016,11(4):e0150806.
[25]BI Y,GAO R,PATEL A,et al.Evidence-based medication use among Chinese patients with acute coronary syndromes at the time of hospital discharge and 1 year after hospitalization:results from the Clinical Pathways for Acute Coronary Syndromes in China(CPACS)study[J].Am Heart J,2009,157(3):509-516.
[26]LI J,CHEN Y,LI X,et al.Use of secondary preventive medications in patients with atherosclerotic disease in urban China:a cross-sectional study of 16,860 patients[J].Chin Med J(Engl),2012,125(24):4361-4367.
[27]GUAN F,XIE J,WANG G,et al.Community-wide survey of physicians'knowledge of cholesterol management[J].Chin Med J(Engl),2010,123(7):884-889.
[28]KO D T,ALTER D A,NEWMAN A M,et al.Association between lipid testing and statin therapy in acute myocardial infarction patients[J].Am Heart J,2005,150(3):419-425.
[29]ELBAROUNI B,BANIHASHEMI S B,YAN R T,et al.Temporal patterns of lipid testing and statin therapy in acute coronary syndrome patients(from the Canadian GRACEExperience)[J].Am J Cardiol,2012,109(10):1418-1424.
[2]LANGENBRUNNER J C,MARQUEZ P V,WANG S.Toward a healthy and harmonious life in china:Stemming the rising tide of non-communicable diseases[N].2011(http://www.worldbank.org).
[3]WANG C,RAO K,WU S,et al.Health care in China:improvement,challenges,and reform[J].Chest,2013,143(2):524-531.
[4]中国卫生和计划生育统计年鉴[S].2013.
[5]SHEIKH K,BULLOCK C.Urban-rural differences in the quality of care for medicare patients with acute myocardial infarction[J].Arch Intern Med,2001,161(5):737-743.
[6]中华人民共和国国家统计局.中国统计年鉴[S].http://www.stats.gov.cn/tjsj/ndsj/2012/indexch.htm,2012.
[7]CHEN W,GAO R,LIU L,et al.China cardiovascular diseases report 2015:a summary[J].J Geriatr Cardiol,2017,14(1):1-10.
[8]BAIGENT C,BLACKWELL L,EMBERSON J,et al.Efficacy and safety of more intensive lowering of LDLcholesterol:a meta-analysis of data from 170 000participants in 26 randomised trials[J].Lancet,2010,376(9753):1670-1681.
[9]BAIGENT C,KEECH A,KEARNEY P M,et al.Efficacy and safety of cholesterol-lowering treatment:prospective meta-analysis of data from 90 056 participants in 14randomised trials of statins[J].Lancet,2005,366(9493):1267-1278.
[10]MIHAYLOVA B,EMBERSON J,BLACKWELL L,et al.The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease:meta-analysis of individual data from 27 randomised trials[J].Lancet,2012,380(9841):581-590.
[11]KEARNEY P M,BLACKWELL L,COLLINS R,et al.Efficacy of cholesterol-lowering therapy in 18 686 people with diabetes in 14 randomised trials of statins:a metaanalysis[J].Lancet,2008,371(9607):117-125.
[12]O'GARA P T,KUSHNER F G,ASCHEIM D D,et al.2013ACCF/AHA guideline for the management of ST-elevation myocardial infarction:a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines[J].J Am Coll Cardiol,2013,61(4):78-140.
[13]ANDERSON J L,ADAMS C D,ANTMAN E M,et al.2012ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction:a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines[J].J Am Coll Cardiol,2013,61(23):179-347.
[14]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.不稳定性心绞痛和非ST段抬高心肌梗死诊断与治疗指南[J].中华心血管病杂志,2007,35(4):295-304.
[15]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.急性ST段抬高型心肌梗死诊断和治疗指南[J].中华心血管病杂志,2010,38(8):675-690.
[16]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.急性ST段抬高型心肌梗死诊断和治疗指南[J].中华心血管病杂志,2015,43(5):380-393.
[17]ROFFI M,PATRONO C,COLLET J P,et al.2015 ESCGuidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation:task force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the european society of cardiology(ESC)[J].Eur Heart J,2016,37(3):267-315.
[18]STEG P G,JAMES S K,ATAR D,et al.ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation[J].Eur Heart J,2012,33(20):2569-2619.
[19]DHARMARAJAN K,LI J,LI X,et al.The China PatientCentered Evaluative Assessment of Cardiac Events(China PEACE)retrospective study of acute myocardial infarction:study design[J].Circ Cardiovasc Qual Outcomes,2013,6(6):732-740.
[20]ANTMAN E M,ANBE D T,ARMSTRONG P W,et al,ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary.Areport of the American college of cardiology/American heart association task force on practice guidelines(Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction)[J].J Am Coll Cardiol,2004,44(3):671-719.
[21]李晶,金泽宁,陈韵岱,等.急性心肌梗死治疗指南对我国住院患者治疗及预后的影响[J].中国危重病急救医学,2010,22(11):649-655.
[22]CHENG T M.Early results of China's historic health reforms:the view from minister Chen Zhu.Interview by TsungMei Cheng[J].Health Aff(Millwood),2012,31(11):2536-2544.
[23]CHEN Y,JIANG L,ZHANG Q,et al.Doctor-reported hospital management of acute coronary syndrome in China:a nationwide survey of 1029 hospitals in 30 provinces[J].World J Card Dis,2012,2(3):168-176.
[24]ZHANG L,LI J,LI X,et al.National Assessment of statin therapy in patients hospitalized with acute myocardial infarction:insight from China PEACE-retrospective AMIstudy,2001,2006,2011[J].PLoS One,2016,11(4):e0150806.
[25]BI Y,GAO R,PATEL A,et al.Evidence-based medication use among Chinese patients with acute coronary syndromes at the time of hospital discharge and 1 year after hospitalization:results from the Clinical Pathways for Acute Coronary Syndromes in China(CPACS)study[J].Am Heart J,2009,157(3):509-516.
[26]LI J,CHEN Y,LI X,et al.Use of secondary preventive medications in patients with atherosclerotic disease in urban China:a cross-sectional study of 16,860 patients[J].Chin Med J(Engl),2012,125(24):4361-4367.
[27]GUAN F,XIE J,WANG G,et al.Community-wide survey of physicians'knowledge of cholesterol management[J].Chin Med J(Engl),2010,123(7):884-889.
[28]KO D T,ALTER D A,NEWMAN A M,et al.Association between lipid testing and statin therapy in acute myocardial infarction patients[J].Am Heart J,2005,150(3):419-425.
[29]ELBAROUNI B,BANIHASHEMI S B,YAN R T,et al.Temporal patterns of lipid testing and statin therapy in acute coronary syndrome patients(from the Canadian GRACEExperience)[J].Am J Cardiol,2012,109(10):1418-1424.