Leape L L, Hilborne L H, Bell R, Kamberg C, Brook R H
RAND, Santa Monica, California 90407, USA.
Ann Intern Med. 1999 Feb 2;130(3):183-92. doi: 10.7326/0003-4819-130-3-199902020-00003.
Women, ethnic minorities, and uninsured persons receive fewer cardiac procedures than affluent white male patients do, but rates of use are crude indicators of quality. The important question is, Do women, minorities, and the uninsured fail to receive cardiac procedures when they need them?
To measure receipt of necessary coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA) overall; by patient sex, ethnicity, and payer status; and by availability of on-site revascularization.
Retrospective, randomized medical record review.
13 of the 24 hospitals in New York City that provide coronary angiography.
631 patients who had coronary angiography in 1992 and met the RAND expert panel criteria for necessary revascularization.
The percentage of patients who had CABG surgery or PTCA was measured, as were variations in use rates by sex, ethnic group, insurance status, and availability of on-site revascularization. Clinical and laboratory data were retrieved from medical records to identify patients who met the panel criteria for necessary revascularization. Receipt of revascularization was determined from state reports, medical records, and information provided by cardiologists.
Overall, 74% (95% CI, 71% to 77%) of patients who met the panel criteria for necessary revascularization had CABG surgery or PTCA (underuse rate, 26%). No differences were found in use rates by patient sex, ethnic group, or payer status, but hospitals that provided on-site revascularization had higher use rates (76% [CI, 74% to 79%]) than hospitals that did not provide it (59% [CI, 56% to 65%]) (P < 0.01). In hospitals that did not provide on-site revascularization, uninsured patients were less likely to have revascularization recommended to them (52% [CI, 32% to 78%]); rates of recommendation for patients with private insurance, Medicare, and Medicaid were 82%, 91%, and 75%, respectively (P = 0.026).
Although revascularization procedures are substantially underused, no variations in rate of use by sex, ethnic group, or payer status were seen among patients treated in hospitals that provide CABG surgery and PTCA. However, underuse was significantly greater in hospitals that do not provide these procedures, particularly among uninsured persons.
与富裕的白人男性患者相比，女性、少数族裔和未参保者接受的心脏手术较少，但使用率只是质量的粗略指标。重要的问题是，女性、少数族裔和未参保者在需要时是否未能接受心脏手术？
总体测量必要的冠状动脉旁路移植术（CABG）和经皮腔内冠状动脉成形术（PTCA）的接受情况；按患者性别、种族和支付者身份；以及按现场血管重建的可及性。
回顾性、随机病历审查。
纽约市24家提供冠状动脉造影的医院中的13家。
1992年进行冠状动脉造影且符合兰德专家小组必要血管重建标准的631例患者。
测量接受CABG手术或PTCA的患者百分比，以及按性别、种族、保险状况和现场血管重建可及性划分的使用率差异。从病历中检索临床和实验室数据，以识别符合专家小组必要血管重建标准的患者。血管重建的接受情况根据州报告、病历和心脏病专家提供的信息确定。
总体而言，符合专家小组必要血管重建标准的患者中，74%（95%CI，71%至77%）接受了CABG手术或PTCA（未充分使用率为26%）。在患者性别、种族或支付者身份方面，使用率未发现差异，但提供现场血管重建的医院使用率较高（76%[CI，74%至79%]），高于未提供的医院（59%[CI，56%至65%]）（P<0.01）。在未提供现场血管重建的医院中，未参保患者接受血管重建建议的可能性较小（52%[CI，32%至78%]）；私人保险、医疗保险和医疗补助患者的建议率分别为82%、91%和75%（P = 0.026）。
尽管血管重建手术的使用率严重不足，但在提供CABG手术和PTCA的医院中，患者的性别、种族或支付者身份的使用率没有差异。然而，在不提供这些手术的医院中，未充分使用率明显更高，尤其是在未参保者中。
