心肌血运重建出院患者随访现况研究

Cross- sectional Study on the Follow-up of Myocardial Revascularization Patients after Discharge

目的：了解心肌血运重建出院患者的随访现况，并探讨在手术实施医院随访者与非手术实施医院随访者的依从性、安全性及经济性。方法选取2013年度在首都医科大学附属北京安贞医院出院的心肌血运重建患者1925例，其中经皮冠状动脉介入术（PCI）1534例，冠状动脉旁路移植术（CABG）391例。根据患者随访机构不同分为手术实施医院组与非手术实施医院组，手术实施医院组数据来源于本院医院信息系统（ HIS），包括门诊及再住院信息；非手术实施医院组数据来源于北京市医保数据，包括门诊与再住院信息。通过随访率、随访次数及人均随访次数指标对不同随访时间、不同随访地点及不同手术方式的人群随访现况进行描述。并记录患者二级预防药物服用率、主要不良心血管事件（ MACE）发生率和门诊费用及住院费用。结果1925例患者平均随访率为94.27％，随访次数共计41774次，人均22次。手术实施医院组1011例（52.52％），平均随访率为94.49％，随访次数共计19834次，人均20次；非手术实施医院组914例（47.48％），平均随访率为94.04％，随访次数共计21940次，人均24次。PCI患者随访率为94.50％，随访次数共计32984次，人均22次；CABG患者平均随访率为93.39％，随访次数共计8790次，人均23次。患者阿司匹林服用率为71.90％（1384/1925），氯吡格雷服用率（仅为 PCI 患者的服用率）为86.11％（1321/1534），他汀类药物服用率为77.40％（1490/1925），β-受体阻滞剂服用率为60.16％（1158/1925），血管紧张素转化酶抑制剂（ACEI）/血管紧张素受体阻滞剂（ARBs）服用率为43.43％（836/1925），双联抗血小板药物服用率（指同时服用阿司匹林和氯吡格雷，仅为PCI患者的服用率）为67.34％（1033/1534）。手术实施医院组和非手术实施医院组他汀类药物、ACEI/ARBs服用率比较，差异均无统计学意义（ P﹥0.05）；手术实施医院组氯吡格雷服用率低于非手术实施医院组，阿司匹林、β-受体阻滞剂、双联抗血小板药物服用率均高于非手术实施医院组（P﹤0.05）。患者在随访期间MACE共发生149例，发生率为7.74％。手术实施医院组MACE发生率为7.22％（73/1011），非手术实施医院组MACE发生率为8.32％（76/914）。两组主要终点事件和次要终点事件发生率比较，差异均无统计学意义（χ^2＝0.429，P＝0.513；χ^2＝0.366，P＝0.545）。患者门诊费用（10166±3198）元，住院费用11665（6862，35185）元。手术实施医院组门诊费用高于非手术实施医院组（t＝9.428，P﹤0.001）；手术实施医院组和非手术实施医院组住院费用比较，差异无统计学意义（ z＝-0.536，P﹥0.050）。结论心肌血运重建出院患者平均随访率为94.27％，人均22次/年。52.52％出院患者继续于手术实施医院进行随访，规范服用二级预防药物比例总体较好，但β-受体阻滞剂与ACEI/ARBs的依从性有待进一步提升，MACE发生率为7.74％。非手术实施医院需进一步强化随访知识，提升其药物治疗的依从性及安全性，分流随访人群，使医疗资源更合理利用。

Objective To understand the follow-up situations of myocardial revascularization patients after discharge and discuss the compliance,safety and economic efficiency. Methods 1 925 cases of myocardial revascularization patients discharged from Beijing Anzhen Hospital, Capital Medical University in 2013 were selected, including 1 534 cases of percutaneous coronary intervention（PCI）and 391 cases of coronary artery bypass grafting（CABG）. According to follow-up institutions,patients were divided into implementation of operation hospital group and non-implementation of operation hospital group. The data of implementation of operation hospital group were collected from the HIS of this hospital,including outpatient and re-hospitalization information. The data of non-implementation of operation hospital group were collected from the data of Beijing medical insurance,including outpatient and re - hospitalization information. The current situations of follow - up of populations at different follow-up times,sites and operation method were described through indexes of follow-up rate,follow-up frequency and average follow-up frequency. Secondary prevention drug taking rate,incidence rate of major adverse cardiac events（ MACE）,outpatient fees and hospitalization expenses of patients were recorded. Results The average follow-up rate of 1 925 cases of patients was 94. 27%. The frequency of follow-up totaled 41 774 times,with an average of 22 times. The implementation of operation hospital group had 1 011 cases （ 52. 52%） with an average follow - up rate of 94. 49%. The frequency of follow-up totaled 19 834 times,with an average of 20 times. The non-implementation of operation hospital group had 914 cases（47. 48%）with an average follow -up rate of 94. 04%. The frequency of follow -up totaled 21 940 times of follow-up,with an average of 24 times. The follow -up rate of PCI patients was 94. 50% and the frequency of follow -up totaled 32 984 times,with an average of 22 times. The follow-up rate of CABG patients was 93. 39% and the frequency of follow-up totaled 8 790 times,with an average of 23 times. The taking rate of aspirin was 71. 90%（1 384/1 925）. The taking rate of clopidogrel（only the taking rate of PCI patients）was 86. 11%（1 321/1 534）. The taking rate of statins was 77. 40%（1 490/1 925）. The taking rate ofβ-receptor blocker was 60. 16%（1 158/1 925）. The taking rate of ACEI/ARBs was 43. 43%（836/1 925）. The taking rate of dual anti -platelet（ which meant to take aspirin and clopidogrel at the same time,only the taking rate of PCI patients） was 67. 34%（1 033/1 534）. The implementation of operation hospital group and non-implementation of operation hospital group were compared in the taking rates of statins and ACEI/ARBs,the differences had no statistical significance（P﹥0. 05）. The taking rate of clopidogrel in implementation of operation hospital group was lower than that in non-implementation of operation hospital group and taking rates of aspirin,β-receptor blocker and dual anti-platelet in implementation of operation hospital group were higher than those in non-implementation of operation hospital group （P﹤0. 05）. 149 cases of patients appeared MACE during the follow -up period,with the incidence rate of 7. 74%. The incidence rate of MACE in implementation of operation hospital group was 7. 22%（73/1 011） and the incidence rate of MACE in non-implementation of operation hospital group was 8. 32% （ 76/914 ）. The occurrence rates of primary endpoint and secondary endpoint were compared and the difference had no statistical significance（χ^2 =0. 429,P=0. 513;χ^2 =0. 366,P=0. 545）. The average outpatient fee was（10 166 ± 3 198）yuan and the hospitalization expenses per capita was 11 665 （6 862,35 185） yuan. The average outpatient fee of implementation of operation hospital group was higher than that of non-implementation of operation hospital group and the difference had statistical significance （ t = 9. 428, P ﹤ 0. 001 ）. The hospitalization expenses of implementation of operation hospital group and non-implementation of operation hospital group were compared and the difference had no statistical significance（z= -0. 536,P﹥0. 050）. Conclusion The average follow-up rate of myocardial revascularization patients after discharge is 94. 27%, with an average of 22 times/year. 52. 52% of the discharged patients were continuously followed up in the implementation of operation hospital,with better total ratio of normatively taking secondary prevention drugs,but the compliance of ACEI/ARBs drugs and β -receptor blocker needed to be improved further,with the incidence rate of MACE of 7. 74%. Non -implementation of operation hospital needs to further strengthen follow-up knowledge,improve the compliance and safety of drug treatment,decentralize follow-up population so as to make useful utilization of medical resources.