研究背景：「搶救失敗死亡率」是近年來逐漸被推廣的手術結果品質指標。不像併發症發生率或死亡率，一般認為搶救失敗死亡率較不受患者本身疾病嚴重度影響。但截至目前為止很少被用於內科侵入性治療的結果評估，包括冠狀動脈介入治療。
研究目的：本研究第一部分嘗試使用「搶救失敗死亡率」作為冠狀動脈介入治療的品質指標。描述各層級醫院在進行冠狀動脈介入治療以後的搶救失敗死亡率差異，及急性或非急性冠狀動脈介入治療搶救失敗死亡率的逐年變化。第二部分使用冠狀動脈介入治療後的死亡個案病歷回顧，試圖釐清冠狀動脈介入治療後的死因分布情形，以及可能發生的搶救失敗死亡的情境。
研究方法：本研究第一部分的資料來源為健保資料庫1997-2012年全住院檔，先選取冠狀動脈介入治療個案。因為急性與非急性冠狀動脈介入治療的嚴重度可能完全不同，所以兩類治療分開處理。急性冠狀動脈介入治療的定義包括：當次診斷出現STEMI或Non-STEMI、不穩定心絞痛、出現惡性心律不整、出現心臟衰竭、之前曾經做過冠狀動脈介入治療或冠狀動脈繞道手術等。定義冠狀動脈介入治療後的併發症選擇包括休克/心跳停止、敗血症、肺炎、深靜脈血栓/肺栓塞、腸胃道出血/急性潰瘍、急性腎衰竭、轉作冠狀動脈繞道手術以及其他相關併發症。計算併發症發生率、校正後的死亡率、以及校正後的搶救失敗死亡率。本研究第二部分是以中部某區域醫院為例，探討「冠狀動脈介入治療搶救失敗死亡」個案的死亡病歷回顧，擷取該醫院2013-2015年在院死亡病例，查詢這些死亡病例的心導管檢查報告以及病歷回顧做分析。
結果：本研究第一部分的資料庫分析以搶救失敗死亡率作為冠狀動脈介入治療的品質指標，從1997年至2012年間，無論急性或非急性冠狀動脈介入治療，搶救失敗死亡率都有下降的趨勢。分層級看校正後死亡率、併發症發生率與校正後搶救失敗死亡率則發現醫學中心的併發症發生機率高於區域醫院，但校正後死亡率與校正後搶救失敗死亡率都是醫學中心優於區域醫院。本研究第二部分的冠狀動脈介入治療後死亡病例研究研究，共找出30位接受冠狀動脈介入治療以後30天內死亡的患者，分析其死亡原因，其中7位(23%)可能與治療直接相關，12位(40%)為其他心臟相關因素，其他11位(37%)則為非心臟相關死因。以搶救失敗死亡率的觀念來看，30位死亡患者中有4位(13%)完全未出現被選取的併發症；30位死亡患者中，有5位(17%)的死亡被認為是可能可以避免的。
結論：使用搶救失敗死亡率作為冠狀動脈介入治療後的結果品質指標可以給我們一些線索，隨著時代演進，搶救失敗死亡率逐漸下降，不同層級間的醫院也出現差異；如此現象背後的脈絡仍須進一步研究釐清。死亡病歷回顧讓我們一窺冠狀動脈介入治療以後死因的分布，並進一步看這些患者出現併發症時，主次診斷的編碼和登錄分布情形，也讓我們知道搶救失敗死亡可能扮演的角色。

SUMMARY
“Failure to rescue” describes clinicians’ inability to save a hospital’s patient’s life when he or she experiences a complication. Until now most articles using this indicator focus on quality surveillance for surgical procedures. In this study we try to clarify the situation of “failure to rescue” for patients receiving percutaneous coronary intervention (PCI). In the first part of the study, PCI procedures were identified from Taiwan National Health Insurance (NHI) inpatient claims database between 1997 and 2012. We find that when patient groups were stratified by the levels of their treating hospitals, patients treated in medical centers had higher complications rates, but lower mortality and failure to rescue rates than those treated in regional hospitals. The trend of failure to rescue rate was decreasing since 1997 to 2012. In the second part of the study, we identified 30 in-hospital mortality cases within 30 days after PCI. Only 23% of deaths were directed related to the procedure, while most of the causes of deaths were related to other cardiac causes or non-cardiac causes. Among these deaths 17% were considered to be probably preventable.

Key words：percutaneous coronary intervention, failure to rescue, causes of death
OBJECTIVES
In the first part of the study, we try to use “failure to rescue” rates as quality indicators after percutaneous coronary intervention (PCI). Failure to rescue rates after PCI in different levels of hospitals will be compared, and the year trend of failure to rescue rates will be studied. In the second part of the study, we will review medical charts of patients who died after PCI within 30 days. We will check the coding of primary and secondary diagnoses to identify the occurrence of complications, the causes of death will also be determined. The situation of “failure to rescue” will be examined.
MATERIALS AND METHODS
In the first part of the study, we used Taiwan National Health Insurance (NHI) inpatient claims data for years 1997 through 2012 to identify PCI cases. The cases were separated into acute and non-acute PCIs since the severity of these two conditions were totally different. Acute PCIs included indications for STEMI, NSTEMI, unstable angina, the presence of malignant arrhythmia, congestive heart failure, or previous PCI/CABG cases. The post-PCI complications included shock, cardiac arrest, sepsis, pneumonia, deep vein thrombosis/pulmonary embolism, GI hemorrhage/acute ulcer, acute renal failure, coronary artery bypass graft, and “other complications due to other cardiac device, implant, and graft”. The complication rates, adjusted mortality rates, and adjusted failure to rescue rates were then calculated. In the second part of the study, we searched the 2012-2015 database of a regional hospital in Taiwan to look for in-hospital mortality cases after PCI. Complete medical charts of the deceased patients were then performed to identify the complications these patients suffered before their demise. The causes of deaths were determined.

RESULTS
The result of the first part of the study showed that both failure to rescue rates for acute or non-acute PCI were decreasing since 1997 to 2012. Patient’s receiving PCIs in medical centers had higher complications rates, but lower adjusted mortality rates and adjusted failure to rescue rates, when compared with patients receiving PCIs in regional hospitals. The result of the second part of the study revealed 30 in-hospital mortality cases after PCIs. After thoroughly reviewing their medical records, 7 of these 30 patients (23%) died directed due to the procedure, 12(40%) died because of other cardiac factors, and 11(37%) died secondary to other non-cardiac factors. 4(13%) patients who died within 30 days were found to be free from the complications we mentioned and tried to discover. 5 deaths (17%) were suspected to be preventable.

CONCLUSION
Failure to rescue may be a useful tool to offer quality measure for hospitals performing PCIs. In this study we found some variation between different levels of hospitals. Also, the failure to rescue rate after PCIs is decreasing overtime. The definite mechanism needs to be clarified in the future. Death review for patients who died after PCIs may remind us some possible coding problems that may be associated with the interpretation of mortality rates and failure to rescue rates. This may also give us some thoughts about how failure to rescue may interfere with the patients’ outcome.

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