Multilevel model analysis for influencing factors of readmission in coronary heart disease patients with heart failure
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摘要:
目的 构建多水平Cox回归模型，分析冠心病合并心力衰竭患者再住院的影响因素。 方法 2014年1月-2017年12月在山西省两所三甲医院连续入选符合标准的1 433例冠心病合并心衰的住院患者。记录患者住院的病历资料（包括基线资料、检查及治疗情况等）并对其进行随访，中位随访期为23个月。应用单因素Cox回归分析及多因素Cox回归分析对自变量进行筛选；采用两水平Cox回归模型进行影响因素的分析。 结果 研究对象中的436（30.4%）例患者发生了再住院，两水平Cox回归分析结果显示高龄（HR=1.010，95%CI：1.001~1.019，P=0.032）、男性（HR=1.234，95%CI：1.009~1.509，P=0.040）、体力劳动（HR=1.458，95%CI：1.036~2.050，P=0.030）、市医保（HR=1.513，95%CI：1.120~2.043，P=0.007）、QRS波间期延长（HR=1.004，95%CI：1.001~1.008，P=0.018）是冠心病合并心力衰竭患者再住院的独立危险因素；高尿比重（HR=0.000，95%CI：0.000~0.059，P=0.021）为冠心病合并心衰患者再住院的保护因素。 结论 年龄、性别、职业、市医保、QRS间期及尿比重是冠心病合并心衰患者再住院的影响因素；加强临床护理监测和完善社会保障制度可以减少患者再住院的发生。 -
关键词:
- 冠心病 /
- 心力衰竭 /
- 再住院 /
- 影响因素 /
- 两水平Cox回归模型
Abstract:Objective To explore the influencing factors of readmission in coronary heart disease patients with heart failure by constructing a multilevel Cox regression model. Methods A total of 1 433 coronary heart disease patients with heart failure were consecutively enrolled, from two hospitals in Shanxi Province from January, 2014 to December, 2017. Patients' medical records (including baseline data, examination and treatment) were recorded and patients were followed up. The median follow-up period was 23 months. Univariate Cox regression analysis and mutivariate Cox regression analysis were used to screen the independent variables. Two-level Cox regression model was used to analyze the influencing factors. Results Rehospitalization occurred in 436(30.4%) cases. Two-level Cox regression model showed that advanced age(HR=1.010, 95% CI: 1.001-1.019, P=0.032), male(HR=1.234, 95% CI: 1.009-1.509, P=0.040), physical labor(HR=1.458, 95% CI: 1.036-2.050, P=0.030), urban medical insurance (HR=1.513, 95% CI: 1.120-2.043, P=0.007), and prolonged QRS interval (HR=1.004, 95% CI: 1.001-1.008, P=0.018) were independent risk factors for readmission coronary heart disease patients with heart failure. High urine specific gravity(HR=0.000, 95% CI: 0.000-0.059, P=0.021) was a protective factor. Conclusions The age, gender, occupation, urban medical insurance, QRS intervall, and urine specific gravity are influencing factors of readmission in coronary heart disease patients with heart failure. Strengthening clinical nursing and monitoring and perfecting social security system can reduce the occurrence of patients' rehospitalization. -
表 1 冠心病合并心力衰竭患者的一般情况[n(%)]
Table 1. General situation of CHD patients with HF [n(%)]
变量 对照组(n=997) 再住院组(n=436) 年龄(岁，x±s) 67.99±11.37 70.84±10.55 性别 男 678(68.0) 286(65.6) 女 319(32.0) 150(34.4) NYHA分级 Ⅱ 374(37.5) 174(39.9) Ⅲ 378(37.9) 152(34.9) Ⅳ 245(24.6) 110(25.2) 职业 体力劳动 310(31.1) 66(15.1) 非体力劳动 687(68.9) 370(84.9) 医保 市医保 515(51.7) 305(70.0) 新农合 361(36.2) 84(19.3) 自费 121(12.1) 47(10.8) 有家族史 189(18.6) 79(18.1) 共病 高血压 610(61.2) 301(69.0) 糖尿病 342(34.3) 148(33.9) 房颤 241(24.2) 108(24.8) 瓣膜病 390(39.1) 155(35.6) 肾功能不全 256(25.7) 122(28.0) PCI 295(29.6) 147(33.7) 
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表 2 冠心病合并心衰患者再住院影响因素与赋值说明
Table 2. Evaluation on influencing factors of readmission in CHD patients with HF
变量 赋值说明 生存结局 未再住院=1，再住院=2 生存时间(d) 实际值(上次出院至下次入院的时间间隔) 年龄(岁) 实际值 性别 男=1，女=2 职业 体力=1，非体力=2 医保种类 市医保=1，新农合=2，全自费=3 肾功能不全 无=1，有=2 舒张功能减低 无=1，有=2 舒张压(mm Hg) <90=1, ≥90=2 血红蛋白(g/L) ≤175(男)，≤150(女)=1 >175(男)，>150(女)=2 AST(U/L) ≤40=1，>40=2 肾小球滤过率(ml/min) ≤125=1，>125=2 尿比重 实际值 QRS波时间(ms) ≤120=1，>120=2 PCI 无=1，有=2
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表 3 冠心病合并心力衰竭患者再住院影响因素的单因素Cox回归分析
Table 3. Analysis of univariate Cox regression for influening factors of readmission in CHD patients with HF
变量 β sx Z值 P值 HR(95%CI)值 性别 0.164 0.086 2.26 0.024 1.180(1.022~1.359) 年龄(岁) 0.020 0.003 5.97 < 0.001 1.020(1.013~1.027) 职业 0.833 0.249 -7.49 < 0.001 2.300(1.860~2.843) 医保种类 全自费 1.000 新农合 -0.293 0.151 -1.94 0.052 0.746(0.555~1.002) 市医保 0.523 0.129 4.06 < 0.001 1.688(1.311~2.173) 肾功能不全 0.242 0.095 3.26 0.001 1.270(1.102~1.473) 舒张压(mm Hg) -0.009 0.003 -2.96 0.003 0.991(0.985~0.997) 血红蛋白(g/L) -0.006 0.002 -3.56 < 0.001 0.994(0.991~0.997) AST(U/L) 0.001 0.000 2.33 0.020 1.000(1.000~1.001) 肾小球滤过率(ml/min) -0.003 0.001 -2.41 0.016 0.997(0.995~0.999) 尿比重 -19.639 6.901 -2.85 0.004 0.000(0.000~0.002) QRS时间(ms) 0.004 0.001 2.71 0.007 1.004(1.001~1.007) 舒张功能减低 0.189 0.083 2.28 0.022 1.208(1.027~1.421) PCI 0.254 0.074 3.42 0.001 1.005(1.114~1.490)
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表 4 冠心病合并心力衰竭患者再住院的多因素Cox回归分析
Table 4. Analysis of mutivariate Cox regression for influencing factors of readmission in CHD patients with HF
变量 β sx Z值 P值 HR(95%CI)值 年龄(岁) 0.011 0.004 3.07 0.002 1.011(1.004~1.018) 性别 0.234 0.078 3.01 0.003 1.263(1.085~1.471) 职业 0.363 0.156 2.33 0.020 1.438(1.060~1.950) 医保种类 全自费 1.000 新农合 -0.100 0.172 -0.58 0.559 0.904(0.646~1.267) 市医保 0.434 0.130 3.33 0.001 1.544(1.195~1.994) 尿比重 -17.650 7.129 -2.48 0.013 0.000(0.000~0.025) QRS时间(ms) 0.005 0.001 3.68 < 0.001 1.005(1.002~1.008) 舒张功能减低 0.170 0.083 2.05 0.041 1.186(1.007~1.396) PCI 0.254 0.074 3.42 0.001 1.005(1.114~1.490)
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表 5 冠心病合并心力衰竭患者再住院的两水平Cox回归分析
Table 5. Analysis of Two-level Cox regression model for influencing factors of readmission in CHD patients with HF
因素 β sx Z值 P值 HR(95%CI)值 年龄(岁) 0.010 0.005 2.14 0.032 1.010(1.001~1.019) 男性 0.210 0.103 2.05 0.040 1.234(1.009~1.509) 体力劳动 0.377 0.174 2.16 0.030 1.458(1.036~2.050) 医保种类 全自费 1.000 新农合 -0.091 0.196 -0.46 0.643 0.913(0.621~1.341) 市医保 0.414 0.153 2.70 0.007 1.513(1.120~2.043) 高尿比重 -18.976 8.237 -2.30 0.021 0.000(0.000~0.059) QRS间期延长 0.004 0.002 2.36 0.018 1.004(1.001~1.008) 舒张功能减低 1.143 0.098 1.46 0.144 1.153(0.952~1.397) PCI 0.178 0.115 1.85 0.064 1.195(0.990~1.443)
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