Nallamothu Brahmajee K, Wang Yongfei, Magid David J, McNamara Robert L, Herrin Jeph, Bradley Elizabeth H, Bates Eric R, Pollack Charles V, Krumholz Harlan M
Health Services Research and Development Center of Excellence, Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA.
Circulation. 2006 Jan 17;113(2):222-9. doi: 10.1161/CIRCULATIONAHA.105.578195. Epub 2006 Jan 9.
Hospitals with primary percutaneous coronary intervention (PPCI) capability may choose to predominately offer PPCI to their patients with ST-segment elevation myocardial infarction (STEMI), or they may selectively offer PPCI or fibrinolytic therapy based on patient and hospital-level factors. Whether a greater level of hospital specialization with PPCI is associated with better quality of care is unknown.
We analyzed data from the National Registry of Myocardial Infarction-4 to compare in-hospital mortality and times to treatment in STEMI across different levels of hospital specialization with PPCI. We divided 463 hospitals into quartiles of PPCI specialization based on the relative proportion of reperfusion-treated patients who underwent PPCI (< or =34.0%, >34.0 to 62.5%, >62.5 to 88.5%, >88.5%). Hierarchical multivariable regression assessed whether PPCI specialization was associated with better outcomes, after adjusting for patient and hospital characteristics, including PPCI volume. We found that greater PPCI specialization was associated with a lower relative risk of in-hospital mortality in patients treated with PPCI (adjusted relative risk comparing the highest and lowest quartiles, 0.64; P=0.006) but not in those treated with fibrinolytic therapy. Compared with patients at hospitals in the lowest quartile of PPCI specialization, adjusted door-to-balloon times in the highest quartile were significantly shorter (99.6 versus 118.3 minutes; P<0.001), and the likelihood of door-to-balloon times exceeding 90 minutes was significantly lower (relative risk, 0.78; P<0.001). Adjusting for PPCI specialization diminished the association between PPCI volume and clinical outcomes.
Greater specialization with PPCI is associated with lower in-hospital mortality and shorter door-to-balloon times in STEMI patients treated with PPCI.
具备直接经皮冠状动脉介入治疗（PPCI）能力的医院，可能会选择主要为其ST段抬高型心肌梗死（STEMI）患者提供PPCI，或者根据患者及医院层面的因素，选择性地提供PPCI或溶栓治疗。PPCI专业化程度更高是否与更好的医疗质量相关尚不清楚。
我们分析了来自国家心肌梗死注册研究-4的数据，以比较不同PPCI专业化水平的医院中STEMI患者的院内死亡率及治疗时间。我们根据接受PPCI再灌注治疗患者的相对比例（≤34.0%、>34.0%至62.5%、>62.5%至88.5%、>88.5%），将463家医院分为PPCI专业化程度的四分位数组。分层多变量回归分析在调整了患者和医院特征（包括PPCI手术量）后，评估PPCI专业化程度是否与更好的预后相关。我们发现，PPCI专业化程度更高与接受PPCI治疗患者的院内死亡相对风险较低相关（比较最高和最低四分位数组的调整后相对风险为0.64；P = 0.006），但与接受溶栓治疗的患者无关。与PPCI专业化程度最低四分位数组医院的患者相比，最高四分位数组患者的调整后门球囊扩张时间显著更短（99.6分钟对118.3分钟；P < 0.001），门球囊扩张时间超过90分钟的可能性显著更低（相对风险为0.78；P < 0.001）。调整PPCI专业化程度后，PPCI手术量与临床结局之间的关联减弱。
PPCI专业化程度更高与接受PPCI治疗的STEMI患者较低的院内死亡率及更短的门球囊扩张时间相关。
