Rumsfeld John S, Magid David J, Peterson Eric D, Plomondon Mary E, Petersen Laura A, Grunwald Gary K, Every Nathan R, Sales Anne E
Cardiology and Health Services Research, Denver VA Medical Center, Denver, CO 80220, USA.
Am Heart J. 2006 Jan;151(1):32-8. doi: 10.1016/j.ahj.2005.03.012.
There is a concern that patients with acute coronary syndrome (ACS) admitted to primary care hospitals (without on-site cardiac procedures) may be at risk for worse outcomes compared with patients admitted to tertiary care hospitals. In addition to mortality, one way to assess patient outcomes is via health status and rehospitalization rates. We compared the health status and rehospitalization of patients with ACS admitted to primary versus tertiary care Veterans Affairs hospitals.
This was a cohort study of 2132 patients with ACS admitted to 21 Veterans Affairs hospitals (12 primary care and 9 tertiary care) from 1998 to 1999. Primary outcomes were 7-month health status as measured by the Seattle Angina Questionnaire and rehospitalization. Hierarchical multivariable regression was used to evaluate the association between admission to a primary (vs tertiary) care hospital and these outcomes. Discharge medications and 7-month cardiac procedure rates were also compared.
There were no significant differences in discharge medication rates between primary and tertiary hospital patients. Forty-two percent of the patients admitted to a primary care hospital was transferred to a tertiary care hospital during index admission. Primary hospital patients had significantly lower 7-month rates of cardiac catheterization (36% vs 51%, P < .001) and percutaneous coronary intervention (11% vs 20%, P < .001), but there were no differences in coronary artery bypass graft surgery rates. After risk adjustment, there were no significant differences in 7-month angina frequency (odds ratio [OR] 0.98, 95% CI 0.78-1.22), physical limitation (OR 0.97, 95% CI 0.77-1.23), quality of life (OR 1.12, 95% CI 0.89-1.40), or rehospitalization (OR 1.07, 95% CI 0.54-2.14) between the 2 groups.
These results suggest that an integrated health care system can achieve similar intermediate-term health status and rehospitalization outcomes for patients with ACS irrespective of the site of admission despite the lower rates of cardiac procedures for the primary care hospital patients.
有人担心，与入住三级护理医院的患者相比，入住基层医疗医院（无现场心脏手术）的急性冠状动脉综合征（ACS）患者可能面临更差的预后风险。除了死亡率，评估患者预后的一种方法是通过健康状况和再住院率。我们比较了入住基层医疗与三级护理退伍军人事务医院的ACS患者的健康状况和再住院情况。
这是一项对1998年至1999年入住21家退伍军人事务医院（12家基层医疗医院和9家三级护理医院）的2132例ACS患者进行的队列研究。主要结局是用西雅图心绞痛问卷测量的7个月健康状况和再住院情况。采用分层多变量回归来评估入住基层（与三级）护理医院与这些结局之间的关联。还比较了出院用药情况和7个月心脏手术率。
基层和三级医院患者的出院用药率没有显著差异。42%入住基层医疗医院的患者在首次住院期间被转至三级护理医院。基层医院患者的7个月心脏导管插入术（36%对51%，P<.001）和经皮冠状动脉介入治疗（11%对20%，P<.001）发生率显著较低，但冠状动脉搭桥手术率没有差异。经过风险调整后，两组之间在7个月心绞痛频率（优势比[OR]0.98，95%可信区间0.78 - 1.22）、身体限制（OR 0.97，95%可信区间0.77 - 1.23）、生活质量（OR 1.12，95%可信区间0.89 - 1.40）或再住院率（OR 1.07，95%可信区间0.54 - 2.14）方面没有显著差异。
这些结果表明，尽管基层医疗医院患者的心脏手术率较低，但在综合医疗保健系统中，无论患者入住何处，ACS患者都能获得相似的中期健康状况和再住院结局。
