Petersen L A, Normand S L, Daley J, McNeil B J
Houston Veterans Affairs Medical Center, and Department of Medicine, Baylor College of Medicine, TX 77030, USA.
N Engl J Med. 2000 Dec 28;343(26):1934-41. doi: 10.1056/NEJM200012283432606.
Some have the opinion that patients cared for in Veterans Health Administration (VHA) hospitals receive care of poorer quality than those cared for in non-VHA institutions. To assess the quality of care in VHA hospitals, we compared the outcome of acute myocardial infarction among patients in VHA and non-VHA institutions while controlling for potential confounders, including coexisting conditions and severity of illness.
We studied 2486 veterans discharged from 81 VHA hospitals and 29,249 Medicare patients discharged from 1530 non-VHA hospitals, restricting our samples to men at least 65 years of age who were discharged with confirmed acute myocardial infarction. We compared coexisting conditions, severity of illness, and 30-day and 1-year mortality in the two samples.
VHA patients were significantly more likely than Medicare patients to have a recorded history of hypertension (64.3 percent vs. 57.3 percent), chronic obstructive pulmonary disease or asthma (30.9 percent vs. 23.5 percent), diabetes (34.8 percent vs. 29.0 percent), stroke (20.4 percent vs. 14.2 percent), or dementia (7.2 percent vs. 4.8 percent) (P<0.001 for all comparisons). According to both multivariate logistic regression and an analysis using 2265 matched pairs of VHA and Medicare patients, there were no significant differences in 30-day or 1-year mortality. The matched-pairs analysis found that the difference in mortality at 30 days (the mortality rate among Medicare patients minus the mortality rate among VHA patients), averaged over the 5-year age groups, was -0.8 percent (95 percent confidence interval, -2.8 percent to 1.3 percent), and the difference in mortality at 1 year was -1.3 percent (95 percent confidence interval, -3.9 percent to 1.3 percent).
VHA patients had more coexisting conditions than Medicare patients. Nevertheless, we found no significant difference in mortality between VHA and Medicare patients, a result that suggests a similar quality of care for acute myocardial infarction.
有些人认为，在退伍军人健康管理局（VHA）医院接受治疗的患者所获得的护理质量低于在非VHA机构接受治疗的患者。为了评估VHA医院的护理质量，我们在控制潜在混杂因素（包括并存疾病和疾病严重程度）的同时，比较了VHA机构和非VHA机构中急性心肌梗死患者的治疗结果。
我们研究了从81家VHA医院出院的2486名退伍军人以及从1530家非VHA医院出院的29249名医疗保险患者，将样本限制为至少65岁且确诊为急性心肌梗死后出院的男性。我们比较了两个样本中的并存疾病、疾病严重程度以及30天和1年死亡率。
VHA患者比医疗保险患者更有可能有高血压病史记录（64.3%对57.3%）、慢性阻塞性肺疾病或哮喘（30.9%对23.5%）、糖尿病（34.8%对29.0%）、中风（20.4%对14.2%）或痴呆（7.2%对4.8%）（所有比较P<0.001）。根据多变量逻辑回归以及对2265对匹配的VHA和医疗保险患者进行的分析，30天或1年死亡率没有显著差异。配对分析发现，在5年年龄组中，30天死亡率的差异（医疗保险患者的死亡率减去VHA患者的死亡率）平均为-0.8%（95%置信区间，-2.8%至1.3%），1年死亡率的差异为-1.3%（95%置信区间，-3.9%至1.3%）。
VHA患者比医疗保险患者有更多的并存疾病。然而，我们发现VHA患者和医疗保险患者之间的死亡率没有显著差异，这一结果表明急性心肌梗死的护理质量相似。
