Skinner Jonathan, Chandra Amitabh, Staiger Douglas, Lee Julie, McClellan Mark
Center for Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, NH 03755, USA.
Circulation. 2005 Oct 25;112(17):2634-41. doi: 10.1161/CIRCULATIONAHA.105.543231.
African Americans are more likely to be seen by physicians with less clinical training or to be treated at hospitals with longer average times to acute reperfusion therapies. Less is known about differences in health outcomes. This report compares risk-adjusted mortality after acute myocardial infarction (AMI) between US hospitals with high and low fractions of elderly black AMI patients.
A prospective cohort study was performed for fee-for-service Medicare patients hospitalized for AMI during 1997 to 2001 (n=1,136,736). Hospitals (n=4289) were classified into approximate deciles depending on the extent to which the hospital served the black population. Decile 1 (12.5% of AMI patients) included hospitals without any black AMI admissions during 1997 to 2001. Decile 10 (10% of AMI patients) included hospitals with the highest fraction of black AMI patients (33.6%). The main outcome measures were 90-day and 30-day mortality after AMI. Patients admitted to hospitals disproportionately serving blacks experienced no greater level of morbidities or severity of the infarction, yet hospitals in decile 10 experienced a risk-adjusted 90-day mortality rate of 23.7% (95% CI 23.2% to 24.2%) compared with 20.1% (95% CI 19.7% to 20.4%) in decile 1 hospitals. Differences in outcomes between hospitals were not explained by income, hospital ownership status, hospital volume, census region, urban status, or hospital surgical treatment intensity.
Risk-adjusted mortality after AMI is significantly higher in US hospitals that disproportionately serve blacks. A reduction in overall mortality at these hospitals could dramatically reduce black-white disparities in healthcare outcomes.
非裔美国人更有可能由临床培训较少的医生诊治，或者在急性再灌注治疗平均时间较长的医院接受治疗。关于健康结果差异的了解较少。本报告比较了老年黑人急性心肌梗死（AMI）患者比例高和低的美国医院之间急性心肌梗死后经风险调整的死亡率。
对1997年至2001年因AMI住院的按服务收费的医疗保险患者进行了一项前瞻性队列研究（n = 1,136,736）。根据医院服务黑人人口的程度，将4289家医院分为大致十分位数。第1分位数（占AMI患者的12.5%）包括1997年至2001年期间没有黑人AMI入院的医院。第10分位数（占AMI患者的10%）包括黑人AMI患者比例最高的医院（33.6%）。主要结局指标为AMI后90天和30天死亡率。入住黑人患者比例过高的医院的患者，其发病程度或梗死严重程度并未更高，但第10分位数医院经风险调整的90天死亡率为23.7%（95%CI 23.2%至24.2%），而第1分位数医院为20.1%（95%CI 19.7%至20.4%）。医院之间结局的差异不能用收入、医院所有权状况、医院规模、人口普查区域、城市状况或医院手术治疗强度来解释。
在美国，服务黑人比例过高的医院中，AMI后经风险调整的死亡率显著更高。降低这些医院的总体死亡率可大幅减少医疗保健结果方面的黑白差距。
