胸痛中心认证与急性冠脉综合征患者服务质量的关联性分析：基于多中心实证研究
Association of Chest Pain Center Accreditation on Care Quality for Patients with Acute Coronary Syndrome: An Empirical Multicenter Study in Beijing
李瑞璇 1周书铎2
作者信息
- 1. 100034 北京市，北京大学第一医院临床流行病学研究室;511436 广东省广州市，广州医科大学卫生管理学院
- 2. 100034 北京市，北京大学第一医院临床流行病学研究室
- 折叠
摘要
背景 胸痛中心（CPC）认证作为提升急性冠脉综合征（ACS）管理质量的重要举措，虽已在我国广泛推广，但其在不同推进阶段对具体服务质量指标的影响仍缺乏系统性评估。目的 系统分析CPC认证前后对ACS患者服务质量的变化，探讨其在院前识别、院内救治及结局改善等方面的实际成效。方法 基于2020年1月—2022年12月北京市18家医院ACS住院患者的电子病历数据，采用自身前后对照设计。根据CPC认证通过时间将患者分为认证前、认证中和认证后，构建广义线性混合模型（GLMM）及混合效应Logistic回归模型，分析院前质量指标、院内过程质量指标以及临床结局指标与认证状态的关系，并进行分层亚组分析。结果 共纳入4 823例患者。在未调整协变量的模型1中，CPC认证状态与D2W时间、抵达时他汀类药物使用、STEMI患者接受直接PCI治疗的比例以及院内死亡情况相关（P<0.05）。进一步在模型2中加入年龄、性别、医院级别、入院生命体征、Killip分级及既往病史等协变量后，上述关联仍存在（P<0.05）。院前质量指标方面：在三级甲等医院患者中，认证中阶段和认证后阶段对从发病到首次医疗接触时间有影响（P70岁老年患者亚组中，仅认证中阶段对呼叫急救时间有影响（P70岁患者及非三级医院患者亚组中，认证后阶段对他汀类药物使用有影响（P<0.05）；在三级甲等医院患者亚组中，仅认证后阶段对他汀类药物使用有影响（P<0.05）；在女性、≤70岁、KillipⅠ~Ⅲ级及非三级医院患者亚组中，认证后阶段对STEMI患者接受直接PCI治疗有影响（P70岁、KillipⅠ~Ⅲ级及非三级医院患者认证后阶段对D2W时间有影响（P<0.001）。在结局指标方面，在KillipⅠ~Ⅲ级及非三级医院患者亚组中，仅认证中阶段对院内死亡有影响（P<0.05）。结论 CPC认证不同推进阶段于院前识别、院内救治及临床结局改善等方面均产生显著效果，一定程度提升了ACS患者服务质量。但院前阶段仍存在进一步优化空间，提示需构建全域胸痛救治体系，促进ACS服务质量的进一步改善。
Abstract
Background Chest Pain Center (CPC) accreditation has been widely implemented in China as a national quality-improvement initiative for acute coronary syndrome (ACS) care. However, evidence remains limited regarding phase specific changes in individual service quality indicators across the accreditation pathway. Objective To examine changes in ACS care quality across the pre-accreditation, during-accreditation, and post-accreditation phases of CPC implementation, with a focus on prehospital identification, in-hospital processes, and in-hospital outcomes. Methods This retrospective study analyzed electronic medical records of hospitalized ACS patients from 18 hospitals in Beijing between January 2020 and December 2022. A self-controlled before-and-after design was employed, and patients were categorized into pre-accreditation, during-accreditation, and post-accreditation groups based on the timing of CPC approval. Generalized linear mixed models (GLMM) and mixed-effects logistic regression models were used to examine associations between CPC accreditation status and prehospital, in-hospital process, and clinical outcome indicators. Subgroup analyses were conducted. Results A total of 4,823 patients were included. In the unadjusted Model 1, CPC accreditation status was significantly associated with Door-to-Wire (D2W) time, statin use on arrival, the proportion of primary percutaneous coronary intervention (PCI) among patients with ST-segment elevation myocardial infarction (STEMI), and in-hospital mortality (P<0.05). After further adjustment for age, sex, hospital level, admission vital signs, Killip class, and medical history in Model 2, all of these associations remained statistically significant (P<0.05). Regarding prehospital quality indicators, among patients treated in tertiary hospitals, both the during-accreditation and post-accreditation phases were associated with symptom onset-tofirst medical contact time (P70 years, only the during-accreditation phase was associated with emergency medical services call time (P70 years, and patients treated in non-tertiary hospitals (P<0.05). Among patients treated in tertiary hospitals, statin use on arrival was associated only with the post accreditation phase (P<0.05). In addition, the post-accreditation phase was associated with the proportion of primary PCI among STEMI patients in female patients, patients aged 70 years, patients with Killip class IIII, and patients treated in non-tertiary hospitals (P70 years, patients with Killip class IIII, and patients treated in non-tertiary hospitals (P < 0.001). Regarding outcome indicators, among patients with Killip class IIII and those treated in non-tertiary hospitals, only the during-accreditation phase was associated with in-hospital mortality (P<0.05). Conclusion CPC accreditation at different implementation phases was associated with significant improvements in prehospital identification, in-hospital management, and clinical outcomes, contributing to an overall enhancement in the quality of care for patients with ACS. However, gaps remain in the prehospital stage, highlighting the need to establish an integrated, region-wide chest pain care system to further improve ACS care quality.关键词
急性冠状动脉综合征/胸痛中心认证/服务质量/多中心研究引用本文复制引用
李瑞璇,周书铎.胸痛中心认证与急性冠脉综合征患者服务质量的关联性分析：基于多中心实证研究[EB/OL].(2025-12-29)[2025-12-31].https://chinaxiv.org/abs/202512.00246.学科分类
临床医学/内科学/基础医学/医学研究方法
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