Allison J J, Kiefe C I, Weissman N W, Person S D, Rousculp M, Canto J G, Bae S, Williams O D, Farmer R, Centor R M
University of Alabama at Birmingham, 1530 Third Ave S, MEB 621, Birmingham, AL 35294-3296, USA.
JAMA. 2000 Sep 13;284(10):1256-62. doi: 10.1001/jama.284.10.1256.
Issues of cost and quality are gaining importance in the delivery of medical care, and whether quality of care is better in teaching vs nonteaching hospitals is an essential question in this current national debate.
To examine the association of hospital teaching status with quality of care and mortality for fee-for-service Medicare patients with acute myocardial infarction (AMI).
DESIGN, SETTING, AND PATIENTS: Analysis of Cooperative Cardiovascular Project data for 114,411 Medicare patients from 4361 hospitals (22,354 patients from 439 major teaching hospitals, 22,493 patients from 455 minor teaching hospitals, and 69,564 patients from 3467 nonteaching hospitals) who had AMI between February 1994 and July 1995.
Administration of reperfusion therapy on admission, aspirin during hospitalization, and beta-blockers and angiotensin-converting enzyme inhibitors at discharge for patients meeting strict inclusion criteria; mortality at 30, 60, and 90 days and 2 years after admission.
Among major teaching, minor teaching, and nonteaching hospitals, respectively, administration rates for aspirin were 91.2%, 86.4%, and 81.4% (P<.001); for angiotensin-converting enzyme inhibitors, 63. 7%, 60.0%, and 58.0% (P<.001); for beta-blockers, 48.8%, 40.3%, and 36.4% (P<.001); and for reperfusion therapy, 55.5%, 58.9%, and 55.2% (P =.29). Differences in unadjusted 30-day, 60-day, 90-day, and 2-year mortality among hospitals were significant at P<.001 for all time periods, with a gradient of increasing mortality from major teaching to minor teaching to nonteaching hospitals. Mortality differences were attenuated by adjustment for patient characteristics and were almost eliminated by additional adjustment for receipt of therapy.
In this study of elderly patients with AMI, admission to a teaching hospital was associated with better quality of care based on 3 of 4 quality indicators and lower mortality. JAMA. 2000;284:1256-1262
在医疗服务提供过程中，成本和质量问题日益重要，在当前这场全国性辩论中，教学医院与非教学医院的医疗质量是否更高是一个关键问题。
研究医院教学状况与急性心肌梗死（AMI）的按服务付费医疗保险患者的医疗质量及死亡率之间的关联。
设计、地点和患者：对来自4361家医院的114411名医疗保险患者的合作心血管项目数据进行分析（439家大型教学医院的22354名患者、455家小型教学医院的22493名患者以及3467家非教学医院的69564名患者），这些患者在1994年2月至1995年7月期间患有AMI。
符合严格纳入标准的患者入院时的再灌注治疗、住院期间的阿司匹林、出院时的β受体阻滞剂和血管紧张素转换酶抑制剂的使用情况；入院后30天、60天、90天及2年的死亡率。
在大型教学医院、小型教学医院和非教学医院中，阿司匹林的使用率分别为91.2%、86.4%和81.4%（P<0.001）；血管紧张素转换酶抑制剂的使用率分别为63.7%、60.0%和58.0%（P<0.001）；β受体阻滞剂的使用率分别为48.8%、40.3%和36.4%（P<0.001）；再灌注治疗的使用率分别为55.5%、58.9%和55.2%（P = 0.29）。各医院未经调整的30天、60天、90天和2年死亡率差异在所有时间段均具有显著统计学意义（P<0.001），死亡率从大型教学医院到小型教学医院再到非教学医院呈递增梯度。通过对患者特征进行调整，死亡率差异有所减弱，而通过对接受治疗情况进行额外调整，差异几乎消除。
在这项针对老年AMI患者的研究中，基于4项质量指标中的3项以及较低的死亡率，入住教学医院与更高的医疗质量相关。《美国医学会杂志》。2000年；284:1256 - 1262
