Influencing factors of 1-year readmission for heart failure patients based on optimal length of stay
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摘要: 目的 评估心力衰竭(心衰)患者住院时间(LOS)与1年内再入院风险的关系，探索最佳LOS患者再入院的影响因素。方法 收集2018-01-01—2020-12-31于川北医学院附属医院心血管内科住院治疗的心衰患者的临床资料，根据住院时间进行分组(LOS1：≤5 d、LOS2：6~10 d、LOS3：11~15 d、LOS4：≥16 d)，通过单因素logistic回归分析展示不同LOS组与再入院的关系，筛选出OR比值最低的LOS组，根据1年内因心衰再入院的随访结果，把OR值最低的LOS患者分为再入院组、非再入院组，比较两组患者之间的基线资料，将差异有统计学意义的变量纳入多因素logistic回归分析，绘制受试者工作特征曲线(ROC)。结果 通过单因素回归分析可知，LOS2组患者OR值最低，共649例患者，其中再入院组为216例，非再入院组为433例；通过多因素logistic回归分析可知吸烟史、血同型半胱氨酸(Hcy)、N型末端脑钠肽前体(NT-proBNP)以及肾小球滤过率(eGFR)是LOS2组心衰患者1年内再入院的独立影响因素(P<0.05)。ROC曲线分析显示吸烟史、Hcy、eGFR、NT-proBNP单独以及联合预测LOS2患者1年内再入院的ROC曲线下面积(AUC)分别为0.594、0.627、0.643、0.733、0.775。结论 LOS2再入院风险最低。吸烟史、Hcy、NT-proBNP以及eGFR在LOS2组患者1年内再入院的风险中表现出良好的预测价值。Abstract: Objective To evaluate the relationship between the length of stay(LOS) and the risk of readmission within 1 year in patients with heart failure, and explore the optimal LOS patients and the influencing factors of readmission.Methods Clinical data of patients with heart failure admitted to the Department of Cardiology, Affiliated Hospital of North Sichuan Medical College, between January 1, 2018 and December 31, 2020 were collected. The patients were categorized into four groups based on their length of stay(LOS1: ≤5 days, LOS2: 6-10 days, LOS3: 11-15 days, LOS4: ≥16 days). Univariate logistic regression analysis was conducted to assess the relationship between the different LOS groups and readmission risk, and the hospitalization period with the lowest odds ratio(OR) was identified. Patients in the LOS group with the lowest OR were further divided into the readmission and non-readmission groups based on their follow-up readmission status within 1 year. Baseline data between the two groups were compared, and variables with statistically significant differences were included in multivariate logistic regression analysis and receiver operating characteristic curve(ROC).Results The LOS2 had the lowest OR value. A total of 649 patients was in LOS2 group, including 216 in the readmission group and 433 in the non-readmission group. Multivariate logistic regression analysis revealed that smoking history, blood homocysteine(Hcy), N-terminal pro-brain natriuretic peptide(NT-proBNP), and glomerular filtration rate(eGFR) were independent influencing factors for 1-year hospital readmission in patients with heart failure in the LOS2 group(P<0.05). ROC curve analysis shows that the area under the ROC curve(AUC) for predicting readmission within 1 year for LOS2 patients based on smoking history, Hcy, NT-proBNP, eGFR as individual predictors and in combination were 0.594, 0.627, 0.643, 0.733, and 0.775, respectively.Conclusion LOS2 had the lowest risk of readmission. The smoking history, Hcy, NT-proBNP, and eGFR are risk factors in the readmission within 1 year for patients in the LOS2 group.
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Key words:
- heart failure /
- length of stay /
- readmission /
- influencing factors /
- risk prediction model
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表 1 不同LOS患者的临床资料
Table 1. Clinical data of different LOS patients
X±S, M(P25, P75), 例(%) 变量 LOS1组(162例) LOS2组(649例) LOS3组(456例) LOS4组(220例) F/H/χ2值 P值 年龄/岁 70.16±12.48 68.93±12.43 71.80±11.16 70.64±11.71 5.289 0.001 男性 91(56.2) 379(58.4) 232(50.9) 121(55.0) 6.185 0.103 BMI/(kg/m2) 22.22±2.71 22.53±2.97 22.32±3.13 22.53±2.95 0.818 0.484 吸烟 63(38.9) 270(41.6) 158(34.6) 84(38.2) 5.487 0.139 饮酒 38(23.5) 204(31.4) 114(25.0) 52(23.6) 9.451 0.024 高血压 68(42.0) 312(48.1) 222(48.7) 123(56.0) 7.608 0.55 糖尿病 27(16.7) 134(20.6) 119(26.1) 76(34.5) 23.325 <0.001 冠心病 105(64.8) 439(67.6) 320(70.2) 160(72.7) 3.587 0.310 心房颤动 56(34.6) 233(36.0) 190(41.7) 77(35.0) 5.265 0.153 COPD 19(11.7) 95(14.6) 83(18.2) 44(20.0) 7.236 0.065 同型半胱氨酸/(μmol/L) 16.71(14.28，19.95) 17.35(14.23，21.15) 17.19(13.90，21.81) 16.40(13.58，20.34) 3.917 0.271 肌酐/(μmol/L) 86.20(68.20，108.00) 83.00(67.00，104.50) 83.30(67.00，105.60) 89.68(70.00，113.50) 8.150 0.043 GFR/(mL/min) 73.55(56.07，90.18) 73.99(55.43，91.12) 70.58(54.73，85.17) 68.09(48.16，83.67) 13.590 0.004 血钠/(mmol/L) 136.05±5.13 136.50±5.21 136.89±4.62 136.23±5.40 1.507 0.211 血钙/(mmol/L) 2.25±0.15 2.24±0.14 2.25±0.14 2.24±0.15 1.155 0.326 血钾/(mmol/L) 3.84±0.71 3.71±0.58 3.73±0.62 3.80±0.80 2.394 0.067 总胆红素/(μmol/L) 16.35(11.30，22.52) 17.40(12.36，24.30) 16.09(12.20，23.30) 16.57(11.53，25.47) 6.578 0.087 甘油三酯/(mmol/L) 1.17(0.87，1.53) 1.09(0.81，1.42) 1.10(0.83，1.45) 1.06(0.82，1.45) 3.797 0.284 NT-proBNP/(pg/mL) 2 249.08(860.00，5 373.00) 2 646.00(957.60，6 437.00) 2 729.00(968.20，6 583.50) 3 627.00(1 372.50，9 951.50) 11.439 0.010 纤维蛋白(原)降解产物/(μg/mL) 3.25(2.20，6.53) 3.10(2.00，5.40) 3.52(2.20，5.88) 3.50(2.30，6.45) 10.227 0.017 VLDL-C/(mmol/L) 0.69±0.36 0.71±0.36 0.71±0.33 0.70±0.37 0.134 0.940 HDL-C/(mmol/L) 1.11±0.39 1.11±0.35 1.12±0.37 1.10±0.41 0.265 0.851 LDL-C/(mmol/L) 2.16±0.76 2.15±0.79 2.13±0.75 2.16±0.80 0.134 0.940 血总胆固醇/(mmol/L) 3.96±1.08 3.96±1.12 3.96±1.07 3.96±1.12 0.002 1.000 血小板计数/(×109/L) 145.50(114.00，197.00) 151.00(112.00，194.00) 158.00(118.50，200.00) 154.00(112.00，213.50) 3.981 0.264 白细胞计数/(×109/L) 6.56(5.38，8.53) 6.54(5.35，8.16) 6.41(5.21，8.11) 7.10(5.73，9.41) 13.413 0.004 凝血酶原时间/s 14.20(13.50，15.40) 14.30(13.50，15.40) 14.30(13.50，15.50) 14.60(13.65，15.65) 5.606 0.132 血红蛋白/(g/L) 122.58±22.41 124.12±22.80 122.18±22.87 118.64±23.40 3.202 0.022 淋巴细胞计数/(×109/L) 1.17(0.83，1.58) 1.18(0.84，1.54) 1.17(0.79，1.54) 1.05(0.74，1.45) 5.839 0.120 左室舒张末期前后径/mm 53.41±8.85 54.41±10.13 53.82±9.63 54.22±10.20 0.613 0.606 左室射血分数/% 51.24±12.95 49.04±13.60 49.42±13.30 48.33±13.63 1.598 0.188 NYHA分级 5.108 0.164 Ⅰ 6(3.7) 43(6.6) 30(6.6) 12(5.5) Ⅱ 55(34.0) 212(32.7) 140(30.7) 60(27.3) Ⅲ 75(46.3) 312(48.1) 213(46.7) 108(49.1) Ⅳ 26(16.0) 82(12.6) 73(16.0) 40(18.2) 住院期间药物服用情况 降血脂药物 104(64.2) 438(67.5) 339(74.3) 157(71.4) 8.776 0.032 利尿剂 149(92.0) 601(92.6) 427(93.6) 209(95.0) 2.013 0.570 β受体阻滞剂 76(46.9) 428(65.9) 330(72.4) 140(63.6) 34.681 <0.001 ACEI/ARB 15(9.3) 119(18.3) 91(20.0) 37(16.8) 9.843 0.020 抗血小板聚集 104(64.2) 478(73.7) 344(75.4) 165(75.0) 8.300 0.040 抗凝药物 63(38.9) 279(43.0) 220(48.2) 108(49.1) 6.930 0.074 注：VLDL-C：极低密度脂蛋白胆固醇；HDL-C：高密度脂蛋白胆固醇；LDL-C：低密度脂蛋白胆固醇。 
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表 2 再入院的单因素logistic回归分析
Table 2. Univariate logistic regression of readmission
类别 β SE Wald χ2值 P值 OR值 95%CI LOS(以LOS2为参考) - - - - - - LOS1 0.447 0.179 6.249 0.012 1.564 (1.101~2.221) LOS3 0.458 0.126 13.217 <0.001 1.580 (1.235~2.022) LOS4 0.750 0.159 22.381 <0.001 2.117 (1.552~2.889) 常量 -0.695 0.083 69.701 <0.001 0.499 -
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表 3 LOS2组再入院与非再入院患者的临床资料比较
Table 3. Clinical data between readmitted and non-readmitted patients in LOS2 group
X±S, M(P25, P75), 例(%) 变量 再入院组(216例) 非再入院组(433例) Z/χ2/t值 P值 年龄/岁 68.89±12.79 68.94±12.26 0.047 0.962 男性 140(64.8) 239(55.2) 5.488 0.019 BMI/(kg/m2) 22.77±3.07 22.57±2.92 0.409 0.683 吸烟 117(54.2) 153(35.3) 21.036 <0.001 饮酒 80(37.0) 124(28.6) 4.718 0.030 高血压 111(51.4) 201(46.4) 1.425 0.233 糖尿病 45(20.8) 89(20.6) 0.007 0.934 冠心病 145(67.1) 294(67.9) 0.039 0.844 心房颤动 79(36.6) 154(35.6) 0.064 0.801 COPD 29(13.4) 66(15.2) 0.381 0.537 Hcy/(μmol/L) 18.96(15.97，23.12) 16.73(13.56，20.28) -5.280 <0.001 肌酐/(μmol/L) 90.55(76.05，122.15) 78.00(63.80，97.20) -5.911 <0.001 GFR/(mL/min) 66.06(48.38，81.46) 77.71(61.12，96.25) -5.957 <0.001 血钠/(mmol/L) 135.91±5.53 136.79±5.03 2.047 0.041 血钙/(mmol/L) 2.24±0.15 2.24±0.13 -0.281 0.779 血钾/(mmol/L) 3.77±0.57 3.68±0.59 -1.905 0.057 总胆红素/(μmol/L) 17.95(13.15，27.63) 17.00(11.97，23.50) -2.102 0.036 甘油三酯/(mmol/L) 1.12(0.83，1.47) 1.06(0.80，1.40) -1.389 0.165 纤维蛋白(原)降解产物/(μg/mL) 3.60(2.30，5.93) 2.89(1.90，5.09) -2.972 0.003 VLDL-C/(mmol/L) 0.67±0.33 0.72±0.37 1.571 0.117 HDL-C/(mmol/L) 1.09±0.38 1.12±0.33 1.089 0.277 LDL-C/(mmol/L) 2.09±0.72 2.17±0.82 1.345 0.179 血总胆固醇/(mmol/L) 3.88±1.10 4.00±1.13 1.806 0.071 血小板计数/(×109/L) 151.00(110.50，191.50) 150.00(113.00，196.00) -0.632 0.527 白细胞计数/(×109/L) 6.80(5.24，8.39) 6.51(5.38，7.99) -0.977 0.328 凝血酶原时间/s 14.60(13.80，15.85) 14.10(13.0，15.20) -3.983 <0.001 血红蛋白/(g/L) 123.32±24.10 124.51±22.14 0.628 0.530 淋巴细胞计数/(×109/L) 1.16(0.83，1.52) 1.19(0.87，1.56) -0.549 0.583 左室舒张末期前后径/mm 57.74±9.93 52.75±9.82 -6.084 <0.001 左室射血分数/% 44.61±13.33 51.26±13.21 6.021 <0.001 NYHA分级 -3.909 <0.001 Ⅰ 8(3.7) 35(8.1) Ⅱ 57(26.4) 155(35.8) Ⅲ 113(52.3) 199(46.0) Ⅳ 38(17.6) 44(10.2) NT-proBNP -10.032 <0.001 ≤1 000 pg/mL 23(10.6) 148(34.2) 1 001~4 000 pg/mL 61(28.2) 171(39.5) 4 001~7 000 pg/mL 31(14.4) 65(15.0) 7 001~10 000 pg/mL 30(13.9) 23(5.3) >10 000 pg/mL 71(32.9) 26(6.0) 住院期间药物服用情况 降血脂药物 144(66.7) 294(67.9) 0.100 0.752 利尿剂 207(95.8) 394(91.0) 4.930 0.026 β受体阻滞剂 149(69.0) 279(64.4) 1.327 0.249 ACEI/ARB 49(22.7) 70(16.2) 4.090 0.043 抗血小板聚集 153(70.8) 325(75.1) 1.325 0.250 抗凝药物 96(44.4) 183(42.3) 0.280 0.597
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表 4 LOS2组患者再入院的多因素logistic回归分析结果
Table 4. Multivariate logistic regression of readmission in LOS2 group
变量 β SE Waldχ2值 P值 OR值 95%CI 吸烟史 0.701 0.194 13.010 <0.001 2.015 (1.377~2.948) Hcy 0.022 0.011 4.054 0.044 1.023 (1.001~1.045) GFR -0.010 0.004 7.955 0.005 0.990 (0.983~0.997) NT-proBNP(以≤1 000 pg/mL为参照) - - - - - - 1 001~4 000 pg/mL 0.768 0.276 7.756 0.005 2.156 (1.256~3.703) 4 001~7 000 pg/mL 1.026 0.325 9.943 0.002 2.791 (1.475~5.282) 7 001~10 000 pg/mL 1.927 0.368 27.387 <0.001 6.868 (3.337~14.132) >10 000 pg/mL 2.735 0.331 68.369 <0.001 15.409 (8.058~29.467) 常量 -1.793 0.449 15.914 <0.001 0.166 -
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