Wiener Renda Soylemez, Welch H Gilbert
Veterans Affairs Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vermont, USA.
JAMA. 2007 Jul 25;298(4):423-9. doi: 10.1001/jama.298.4.423.
Although there is now substantial evidence that pulmonary artery (PA) catheterization does not reduce mortality in critically ill patients, it is unknown whether national utilization has decreased in response.
To determine trends in PA catheterization use in the United States.
DESIGN, SETTING, AND PARTICIPANTS: A time trend analysis on national estimates of PA catheterization utilization from 1993-2004 using data from all US states contributing to the Nationwide Inpatient Sample. Hospital admissions for those participants aged 18 years or older were assessed, with primary analysis focused on admissions with a medical diagnosis related group and a secondary analysis focused on surgical admissions. PA catheterization was identified by 5 International Classification of Diseases, Ninth Revision procedure codes describing PA or wedge-pressure monitoring, measurement of mixed venous blood gases, or monitoring of cardiac output by oxygen consumption or other technique.
Annual PA catheterization use per 1000 medical admissions.
Between 1993 and 2004, PA catheterization use decreased by 65% from 5.66 to 1.99 per 1000 medical admissions (risk ratio [RR], 0.35; 95% confidence interval [CI], 0.29-0.42). Among patients who died during hospitalization, a group whose disease severity may be consistent across time, the relative decline was similar, decreasing from 54.7 to 18.1 per 1000 deaths (RR, 0.33; 95% CI, 0.28-0.38). A significant change in trend occurred following a 1996 study that suggested increased mortality with PA catheterization. The decline in utilization was similar in surgical patients (RR, 0.37; 95% CI, 0.25-0.49). Among common diagnoses associated with PA catheterization, the decline was most prominent for myocardial infarction, which decreased by 81% (RR, 0.19; 95% CI, 0.15-0.23), and least prominent for septicemia, which decreased by 54% (RR, 0.46; 95% CI, 0.38-0.54). Sensitivity analyses suggested findings were not due to artifact of changing procedure coding practice.
Use of the PA catheter, previously a hallmark of critical care practice, has decreased in the United States during the last decade, possibly due to growing evidence that this invasive procedure does not reduce mortality.
尽管目前有大量证据表明肺动脉导管插入术并不能降低重症患者的死亡率，但尚不清楚全国范围内该技术的使用是否因此而减少。
确定美国肺动脉导管插入术的使用趋势。
设计、设置和参与者：利用美国所有州提供给全国住院患者样本的数据，对1993 - 2004年全国肺动脉导管插入术使用情况的估计进行时间趋势分析。对18岁及以上参与者的医院入院情况进行评估，主要分析集中在患有医疗诊断相关组的入院患者，次要分析集中在手术入院患者。通过5个国际疾病分类第九版程序编码来识别肺动脉导管插入术，这些编码描述了肺动脉或楔压监测、混合静脉血气测量或通过氧耗量或其他技术监测心输出量。
每1000例医疗入院患者的年度肺动脉导管插入术使用情况。
1993年至2004年期间，每1000例医疗入院患者的肺动脉导管插入术使用率从5.66降至1.99，下降了65%（风险比[RR]，0.35；95%置信区间[CI]，0.29 - 0.42）。在住院期间死亡的患者中（这组患者的疾病严重程度可能随时间保持一致），相对下降情况相似，每1000例死亡患者中的使用率从54.7降至18.1（RR，0.33；95% CI，0.28 - 0.38）。1996年一项表明肺动脉导管插入术会增加死亡率的研究之后，出现了显著的趋势变化。手术患者的使用率下降情况相似（RR，0.37；95% CI，0.25 - 0.49）。在与肺动脉导管插入术相关的常见诊断中，心肌梗死的下降最为显著，下降了81%（RR，0.19；95% CI，0.15 - 0.23），败血症的下降最不显著，下降了54%（RR，0.46；95% CI，0.38 - 0.54）。敏感性分析表明研究结果并非由于程序编码实践变化的人为因素导致。
肺动脉导管，以前是重症监护实践的一个标志，在过去十年中在美国的使用有所减少，这可能是由于越来越多的证据表明这种侵入性操作并不能降低死亡率。
