Udvarhelyi I S, Gatsonis C, Epstein A M, Pashos C L, Newhouse J P, McNeil B J
Department of Health Care Policy, Harvard Medical School, Boston, Mass 02115.
JAMA. 1992 Nov 11;268(18):2530-6.
To describe the process of care and clinical outcomes associated with acute myocardial infarction (AMI) in the Medicare population, and to examine differences in process of care and outcome of care as a function of patient age, gender, and race.
Retrospective cohort study using a longitudinal database created from Medicare utilization and administrative files. PATIENT POPULATIONS: A cohort of AMI patients covered by Medicare in 1987 and a random sample of Medicare patients without AMI. MAIN PROCESS AND OUTCOME MEASUREMENTS: (1) The use of coronary angiography, coronary artery bypass graft surgery, and percutaneous transluminal coronary angioplasty during the first 90 days after a new AMI; (2) mortality at 30 days, 1 year, and 2 years; (3) reinfarction rates; and (4) reoperation rates for coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty.
Mortality rates were high: 26% at 30 days, 40% at 1 year, and 47% at 2 years. They varied greatly by age, less so by gender and race, and were high even among patients who survived the first 30 days. Compared with mortality, reinfarction was uncommon, occurring in 7.3% of patients. During the first 90 days, 23% of all patients underwent angiography and 13% underwent coronary revascularization (coronary artery bypass graft surgery, 8%; percutaneous transluminal coronary angioplasty, 5%). The use of all three procedures decreased with age and was less common among women and blacks than among men and whites. Differential use by age and race was greater for angiography than for revascularization procedures.
The prognosis following AMI in patients aged 65 years and above is much worse than is commonly realized. Procedure use in these patients varies as a function of gender and race, even though mortality does not. Further research is needed to reduce the mortality of elderly patients with AMI and to understand the significance of differences in procedure use on the basis of sociodemographic characteristics.
描述医疗保险人群中与急性心肌梗死（AMI）相关的护理过程及临床结局，并探讨护理过程和护理结局在患者年龄、性别和种族方面的差异。
利用医疗保险使用情况和管理档案建立的纵向数据库进行回顾性队列研究。
1987年医疗保险覆盖的AMI患者队列以及无AMI的医疗保险患者随机样本。
（1）新发AMI后前90天内冠状动脉造影、冠状动脉旁路移植术和经皮腔内冠状动脉成形术的使用情况；（2）30天、1年和2年时的死亡率；（3）再梗死率；（4）冠状动脉旁路移植术和经皮腔内冠状动脉成形术的再次手术率。
死亡率较高：30天时为26%，1年时为40%，2年时为47%。死亡率因年龄差异很大，因性别和种族差异较小，且即使在度过最初30天的患者中也很高。与死亡率相比，再梗死并不常见，7.3%的患者发生再梗死。在前90天内，所有患者中有23%接受了血管造影，13%接受了冠状动脉血运重建（冠状动脉旁路移植术，8%；经皮腔内冠状动脉成形术，5%）。这三种手术的使用随年龄增长而减少，在女性和黑人中比在男性和白人中更不常见。血管造影在年龄和种族方面的差异使用比血运重建手术更大。
65岁及以上患者AMI后的预后比通常认为的要差得多。这些患者的手术使用因性别和种族而异，尽管死亡率并非如此。需要进一步研究以降低老年AMI患者的死亡率，并了解基于社会人口学特征的手术使用差异的意义。
