Ezekowitz Justin A, van Walraven Carl, McAlister Finlay A, Armstrong Paul W, Kaul Padma
Division of Cardiology, University of Alberta, Edmonton, Alta.
CMAJ. 2005 Jan 18;172(2):189-94. doi: 10.1503/cmaj.1032017.
There is uncertainty about whether physician specialty influences the outcomes of outpatients with congestive heart failure after adjustment for differences in case mix. Our objective was to determine the impact of physician specialty on outcomes in outpatients with new-onset congestive heart failure.
The study was a population-based retrospective cohort study involving patients with new-onset congestive heart failure discharged from 128 acute care hospitals in Alberta between Apr. 1, 1998, and July 1, 2000. Outcomes were resource utilization (clinic visits, emergency department visits and hospital admissions) and survival at 30 days and 1 year.
A total of 3136 patients were discharged from hospital with a new diagnosis of congestive heart failure (median age 76 years, 50% men). Of these, 1062 (34%) received no follow-up visits for cardiovascular care, 738 (24%) were seen by a family physician (FP) alone, 29 (1%) by a specialist (cardiologist or general internist) alone and 1307 (42%) by both a specialist and an FP. Compared with patients who received no follow-up cardiovascular care, patients who received regular cardiovascular follow-up visits with a physician had fewer visits to the emergency department (38% v. 80%), fewer were admitted to hospital (13% v. 94%), and the adjusted 1-year mortality was lower (22% v. 37%) (all p < 0.001). Compared with patients who received combined specialist and FP care, patients cared for exclusively by FPs had fewer outpatient visits (median 9 v. 17 in the first year), fewer of these patients presented to the emergency department (24% v. 45% in the first year), and fewer were readmitted for cardiovascular care (7% v. 16%) (all p < 0.001). However, the adjusted mortality at 1 year was lower among patients treated with combined care (17% v. 28%, p < 0.001) despite a higher burden of comorbidities. In a multivariate model adjusting for comorbidities (with no cardiovascular follow-up visits as the reference category), the mortality was lower among patients followed on an outpatient basis by an FP alone (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.53-0.82) or by an FP and a specialist (OR 0.34, 95% CI 0.28-0.42). In a proportional hazards model with time-dependent covariates (with adjustment for frequency of follow-up visits), the risk of all-cause mortality was reduced significantly (hazard ratio 0.98, 95% CI 0.97- 0.99) with each specialist visit compared with FP care alone.
Patients with congestive heart failure followed by both specialists and FPs had significantly better survival than those followed by FPs alone (or those who received no specific cardiovascular follow-up care). Methods to improve timely and appropriate access to specialists and to improve collaborative care structures are needed.
在对病例组合差异进行调整后，医师专业是否会影响充血性心力衰竭门诊患者的治疗结果尚不确定。我们的目的是确定医师专业对新发充血性心力衰竭门诊患者治疗结果的影响。
该研究是一项基于人群的回顾性队列研究，涉及1998年4月1日至2000年7月1日期间从艾伯塔省128家急症医院出院的新发充血性心力衰竭患者。治疗结果包括资源利用情况（门诊就诊、急诊科就诊和住院情况）以及30天和1年时的生存率。
共有3136例患者因新发充血性心力衰竭出院（中位年龄76岁，50%为男性）。其中，1062例（34%）未接受心血管护理随访，738例（24%）仅由家庭医生诊治，29例（1%）仅由专科医生（心脏病专家或普通内科医生）诊治，1307例（42%）由专科医生和家庭医生共同诊治。与未接受心血管护理随访的患者相比，接受医生定期心血管随访的患者急诊科就诊次数更少（38%对80%），住院人数更少（13%对94%），调整后的1年死亡率更低（22%对37%）（所有p<0.001）。与接受专科医生和家庭医生联合治疗的患者相比，仅由家庭医生治疗的患者门诊就诊次数更少（第一年中位就诊次数为9次对17次），这些患者中到急诊科就诊的人数更少（第一年为24%对45%），因心血管护理再次住院的人数更少（7%对16%）（所有p<0.001）。然而，尽管合并症负担较高，但联合治疗患者的1年调整死亡率较低（17%对28%，p<0.001）。在一个调整了合并症的多变量模型中（以未进行心血管随访为参考类别），仅由家庭医生进行门诊随访的患者死亡率较低（比值比[OR]0.66，95%置信区间[CI]0.53 - 0.82），由家庭医生和专科医生进行门诊随访的患者死亡率更低（OR 0.34，95%CI 0.28 - 0.42）。在一个具有时间依赖性协变量的比例风险模型中（对随访就诊频率进行调整），与仅由家庭医生治疗相比，每次专科医生就诊可显著降低全因死亡风险（风险比0.98，95%CI 0.97 - 0.99）。
由专科医生和家庭医生共同随访的充血性心力衰竭患者的生存率显著高于仅由家庭医生随访的患者（或未接受特定心血管随访护理的患者）。需要采取措施改善及时、适当获得专科医生服务的机会，并改善协作护理结构。
