Baldwin Laura-Mae, MacLehose Richard F, Hart L Gary, Beaver Shelli K, Every Nathan, Chan Leighton
University of Washington, Department of Family Medicine, Box 354982, Seattle, WA 98195, USA.
J Rural Health. 2004 Spring;20(2):99-108. doi: 10.1111/j.1748-0361.2004.tb00015.x.
Acute myocardial infarction (AMI) is a common and important cause of admission to US rural hospitals, as transport of patients with AMI to urban settings can result in unacceptable delays in care.
To examine the quality of care for patients with AMI in rural hospitals with differing degrees of remoteness from urban centers.
This cohort study used data from the Cooperative Cardiovascular Project (CCP), including 4,085 acute care hospitals (408 remote small rural, 893 small rural, 619 large rural, and 2,165 urban) with 135,759 direct admissions of Medicare beneficiaries ages 65 and older for a confirmed AMI between February 1994 and July 1995. Outcomes included use of aspirin, reperfusion, heparin, and intravenous nitroglycerin during hospitalization; use of beta-blockers, aspirin, and angiotensin-converting enzyme (ACE) inhibitors at discharge; avoidance of calcium channel blockers at discharge; and 30-day mortality.
Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive the recommended treatments for AMI. Medicare patients in rural hospitals were less likely than urban hospitals' patients to receive aspirin, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only ACE inhibitors at discharge was used more for patients in rural hospitals than urban hospitals. Medicare patients in rural hospitals had higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals (odds ratio for large rural 1.14 [1.10 to 1.18], small rural 1.24 [1.20 to 1.29], remote small rural 1.32 [1.23 to 1.41]).
Efforts are needed to help hospital medical staffs in both rural and urban areas develop systems to ensure that patients receive recommended treatments for AMI.
急性心肌梗死（AMI）是美国农村医院常见且重要的住院原因，因为将急性心肌梗死患者转运至城市医院可能导致护理延误，这种延误令人无法接受。
研究与城市中心距离不同的农村医院中急性心肌梗死患者的护理质量。
这项队列研究使用了合作心血管项目（CCP）的数据，该数据包括4085家急症医院（408家偏远小型农村医院、893家小型农村医院、619家大型农村医院和2165家城市医院），在1994年2月至1995年7月期间，有135759名65岁及以上的医疗保险受益人因确诊急性心肌梗死而直接入院。结果包括住院期间阿司匹林、再灌注治疗、肝素和静脉注射硝酸甘油的使用情况；出院时β受体阻滞剂、阿司匹林和血管紧张素转换酶（ACE）抑制剂的使用情况；出院时避免使用钙通道阻滞剂；以及30天死亡率。
城市和农村医院中相当比例的医疗保险受益人未接受急性心肌梗死的推荐治疗。农村医院的医疗保险患者比城市医院的患者更不可能接受阿司匹林、静脉注射硝酸甘油、肝素以及溶栓治疗或经皮冠状动脉腔内血管成形术。只有出院时使用ACE抑制剂的农村医院患者比城市医院患者更多。农村医院的医疗保险患者急性心肌梗死后30天的全因调整死亡率高于城市医院患者（大型农村医院的比值比为1.14[1.10至1.18]，小型农村医院为1.24[1.20至1.29]，偏远小型农村医院为1.32[1.23至1.41]）。
需要努力帮助农村和城市地区的医院医务人员建立系统，以确保患者接受急性心肌梗死的推荐治疗。
