Stewart S, Demers C, Murdoch D R, McIntyre K, MacLeod M E, Kendrick S, Capewell S, McMurray J J V
Clinical Research Initiative in Heart Failure, University of Glasgow, Glasgow, Scotland, U.K.
Eur Heart J. 2002 Apr;23(8):650-7. doi: 10.1053/euhj.2001.2890.
Following hospitalization with a range of cardiovascular disorders, substantial variation has been noted in clinical outcome, both between and within countries.
To examine the variation, between hospitals, in the clinical outcomes of death and readmission following hospitalization with heart failure in Scotland. Setting All 29 acute hospitals in Scotland with more than 200 beds.
All 31 452 patients discharged from these hospitals between January 1990 and December 1995 with a first-ever, primary, diagnosis at discharge/death of heart failure.
An analysis of the Scottish database of discharge summaries linking index admissions with subsequent admissions and deaths. Death rates and readmission rates were adjusted for baseline age, co-morbidity and socio-economic status and were calculated at different time periods (inpatient, 30 days, 1 year). Rates were calculated separately for large teaching hospitals (n=6, category A), large general hospitals with specialist units (n=8, category B) and medium sized general hospitals with limited specialist units (n=15 category C).
A total of 31 452 patients were discharged between 1990-1995 - 10 219 (33%), 9735 (31%) and 11 498 (37%) to category A, B and C hospitals, respectively. The national, average, inpatient case fatality rate was 15.3%, ranging, in individual hospitals, from the lowest rate of 8.5% to the highest rate of 23.4%. The average 1 year case fatality rate was 42.4%, ranging between 35.3% and 50.8%. A similar two- to threefold variation was found in hospital readmission rates - thus the average 30 day readmission rate was 5.3% (lowest 3.3%, highest 7.3%). This variation, in both case-fatality and readmission rates, was apparent within all three groups of hospitals and persisted after adjustment for the baseline factors outlined above.
A patient admitted to one Scottish hospital with heart failure may be two to three times more likely to die or be readmitted, both in the short and longer term, compared to a patient admitted to another hospital. Although we may not have accounted for some sources of variation, it is both surprising and disturbing that large, statistically significant, differences in adjusted death and readmission rates can apparently exist for such an important condition in a relatively small country with generally homogenous health care provision. Further, detailed investigation of this apparent variation is required.
一系列心血管疾病患者住院后，各国之间以及各国国内的临床结局都存在很大差异。
研究苏格兰心力衰竭患者住院后，不同医院之间死亡和再入院的临床结局差异。研究地点为苏格兰所有29家床位超过200张的急症医院。
1990年1月至1995年12月期间，从这些医院出院的所有31452例患者，出院/死亡时首次诊断为原发性心力衰竭。
对苏格兰出院小结数据库进行分析，将首次入院与后续入院及死亡情况相联系。根据基线年龄、合并症和社会经济状况对死亡率和再入院率进行调整，并在不同时间段（住院期间、30天、1年）进行计算。分别计算大型教学医院（n = 6，A类）、设有专科病房的大型综合医院（n = 8，B类）和设有有限专科病房的中型综合医院（n = 15，C类）的比率。
1990 - 1995年间共有31452例患者出院，分别有10219例（33%）、9735例（31%）和11498例（37%）入住A、B、C类医院。全国平均住院病死率为15.3%，各医院病死率从最低的8.5%到最高的23.4%不等。平均1年病死率为42.4%，在35.3%至50.8%之间。医院再入院率也存在类似的两到三倍差异，因此平均30天再入院率为5.3%（最低3.3%，最高7.3%）。病死率和再入院率的这种差异在所有三类医院中都很明显，在对上述基线因素进行调整后依然存在。
与入住另一家医院的心力衰竭患者相比，入住一家苏格兰医院的患者在短期和长期内死亡或再次入院的可能性可能高出两到三倍。尽管我们可能没有考虑到某些差异来源，但在一个医疗服务普遍同质化的相对小国，对于这样一种重要疾病，经调整后的死亡率和再入院率存在如此大的、具有统计学意义的差异，既令人惊讶又令人不安。此外，需要对这种明显的差异进行进一步详细调查。
