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门诊护理医生的专业特长与老年心肌梗死患者的死亡率

Specialty of ambulatory care physicians and mortality among elderly patients after myocardial infarction.

作者信息

Ayanian John Z, Landrum Mary Beth, Guadagnoli Edward, Gaccione Peter

机构信息

Department of Medicine, Division of General Medicine and Primary Care, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.

出版信息

N Engl J Med. 2002 Nov 21;347(21):1678-86. doi: 10.1056/NEJMsa020080.

Abstract

BACKGROUND

The outcome after myocardial infarction may be influenced by the type of physician providing ambulatory care.

METHODS

We studied 35,520 patients 65 years of age or older who were hospitalized for myocardial infarction in seven states during 1994 and 1995 and who survived for at least three months after discharge. From Medicare claims, we identified ambulatory visits to cardiologists, internists, and family practitioners. Using propensity scores to adjust for demographic, clinical, and hospital characteristics, we analyzed treatment and mortality at two years among patients matched according to their estimated propensity to receive care from a cardiologist within three months after discharge.

RESULTS

As compared with patients who saw only an internist or a family practitioner in the three months after discharge, patients who saw a cardiologist were younger, were more likely to be white, were more likely to be male, had fewer coexisting conditions, and were more likely to have undergone invasive cardiac procedures while hospitalized (P<0.01 for all comparisons). Patients who saw a cardiologist were more likely to undergo cardiac procedures and rehabilitation after discharge. Patients who saw a cardiologist had a lower two-year mortality rate than matched patients who saw only an internist or a family practitioner (14.6 percent vs. 18.3 percent, P<0.001). Patients who saw both a cardiologist and an internist or a family practitioner had a lower mortality rate than matched patients who saw only a cardiologist (11.1 percent vs. 12.1 percent, P=0.02).

CONCLUSIONS

Ambulatory visits to cardiologists were associated with greater use of cardiac procedures and decreased mortality after myocardial infarction. Concurrent care by an internist or a family practitioner was associated with a further reduction in mortality.

摘要

背景

心肌梗死后的预后可能会受到提供门诊护理的医生类型的影响。

方法

我们研究了1994年和1995年期间在七个州因心肌梗死住院且出院后存活至少三个月的35520名65岁及以上的患者。通过医疗保险理赔记录,我们确定了患者对心脏病专家、内科医生和家庭医生的门诊就诊情况。利用倾向得分来调整人口统计学、临床和医院特征,我们分析了根据出院后三个月内接受心脏病专家治疗的估计倾向进行匹配的患者在两年后的治疗情况和死亡率。

结果

与出院后三个月内仅看内科医生或家庭医生的患者相比,看心脏病专家的患者更年轻,更可能是白人,更可能是男性,并存疾病更少,住院期间接受侵入性心脏手术的可能性更大(所有比较P<0.01)。看心脏病专家的患者出院后更可能接受心脏手术和康复治疗。看心脏病专家的患者两年死亡率低于仅看内科医生或家庭医生的匹配患者(14.6%对18.3%,P<0.001)。既看心脏病专家又看内科医生或家庭医生的患者死亡率低于仅看心脏病专家的匹配患者(11.1%对12.1%,P=0.02)。

结论

门诊就诊心脏病专家与心肌梗死后更多地使用心脏手术和降低死亡率相关。内科医生或家庭医生的联合护理与进一步降低死亡率相关。

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