The construction of quality assessment model for highly time-dependency customers─ Examplified by ST-segment elevation myocardial infarction patients in the emergency department of a medical center
Date Issued
2015
Date
2015
Author(s)
Liao, Pei-Ju
Abstract
Cardiovascular diseases, including heart diseases, have been listed at the 2nd place of leading causes of death in Taiwan since 2012. Heart diseases, particularly acute coronary syndromes (ACS), affect human’s health and longevity while causing enormous burden of economic cost of the society. Over half of ACS patients are diagnosed as acute ST-segment elevation myocardial infarction (STEMI) of which is granted as a highly fatal disease and requires timely treatment to prevent further cardiac injuries. Percutaneous coronary intervention (PCI) is currently the primary treatment for STEMI patients, which is suggested to be administered within 12 hours after onset and within 90 minutes after admitted to emergency department (door-to-balloon time, D2B). To improve the care quality, this study aims to analyze factors associated with STEMI prognosis and the subsequent economic impacts. This study is a retrospective database prospective analysis. A total 662 STEMI patients admitted to the emergency department (ED) of a medical center in northern Taiwan during 2010-2012 were analyzed. Demographic background, comorbidity, physiological indicators, cardiac injury information, treatment record, time interval at presence, waiting time for electrocardiogram examination , and D2B were used to examine factors associated with prognoses and medical consumptions, the primary outcomes of this study. Poor prognoses included in-hospital death and discharge against medical advises. Medical consumptions included total medical expenses and total length of stay. Multiple logistic regression and general linear model were used. Receiver operating characteristic curve was utilized to determine the predictability of factors to patient’s poor prognosis. The study has demonstrated that patient’s age (OR=1.07;95% CI=1.04-1.10), and patients diagnosed with upper gastrointestinal hemorrhage or ulcer (OR=3.43; 95% CI=1.26-9.38), respiratory failure (OR=4.77; 95% CI=2.03-11.19), renal failure or acute renal injury (OR=5.43; 95% CI=2.15-13.74), or shock (OR=12.61; 95% CI=5.75-27.64) were significantly associated with poor prognosis. A relatively late PCI treatment (D2B>60 minutes) was also associated with folds of relative elevation of poor prognosis at 2.20, 1.99, 5.89, and 7.45 among patients older than 65 years old, with respiratory failure, with shock, and with renal failure or acute renal injury, respectively. PCI treatment history, presence of respiratory failure, and number of infarcted vessel were associated with total medical expenses. A prompt PCI treatment (D2B≦60 minutes) could reduce 5.7% (NT$ 13,896) and 18.4% (NT$ 46,062) of total medical expenses among patients with two and three infarcted vessels, respectively. Female, presence with chronic obstructive pulmonary disease (COPD) or respiratory failure, and higher KILLIP class were associated with total length of stay. A prompt PCI treatment (D2B≦60 minutes) could reduce 46.7% (10.5 days) of total length of stay among patients with COPD. This study has constructed a scoring system, including age >65 years old, and presence with shock, respiratory failure, renal failure or acute renal injury, and upper gastrointestinal hemorrhage or ulcer, to predict patient’s prognosis. Patients with >10 risk score are at high risk of poor prognosis. A high risk of poor prognosis was found among patients with >23 risk score while taking D2B time regimen into the predictive model. Although STEMI patients are generally classified as high urgent ED patients, to characterize the patients with extremely high fatality is especially important for emergency care. Providing prompt medical interventions to highly fatal patients is particularly beneficiary to both life-saving and medical cost containments. This study provides clues for future care quality improvements among STEMI patients, which also encompasses mechanistic pathways for health care quality, cost effectiveness, and management of time-dependency diseases in the future.
Subjects
care quality
emergency medicine
ST-segment elevation myocardial infarction
percutaneous coronary intervention
prognosis
medical consumptions
risk assessment
SDGs
Type
thesis
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