Ko Dennis T, Wang Yongfei, Alter David A, Curtis Jeptha P, Rathore Saif S, Stukel Therese A, Masoudi Fredrick A, Ross Joseph S, Foody JoAnne M, Krumholz Harlan M
Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
J Am Coll Cardiol. 2008 Feb 19;51(7):716-23. doi: 10.1016/j.jacc.2007.10.039.
We evaluated whether appropriateness and baseline risk of cardiac catheterization varied according to regional intensity of invasive therapy after acute myocardial infarction (AMI), and whether AMI mortality varied according to invasive intensity regions.
Marked regional variations exist in cardiac invasive procedure use after AMI within the U.S.
We performed an analysis of 44,639 Medicare fee-for-service beneficiaries hospitalized with AMI between 1998 and 2001. Invasive procedure intensity was determined based on overall cardiac catheterization rates for Medicare enrollees. Cardiac catheterization appropriateness was determined by the American College of Cardiology/American Heart Association classification and baseline risk was estimated using the GRACE (Global Registry of Acute Coronary Events) risk score. The primary outcomes of the study were cardiac catheterization use within 60 days and 3-year mortality after hospital admission.
Higher invasive intensity regions were more likely to perform cardiac catheterizations on class I patients (appropriate) (RR 1.38, 95% confidence interval [CI] 1.27 to 1.48), class II patients (equivocal) (RR 1.42, 95% CI 1.31 to 1.53), and class III patients (inappropriate) (RR 1.29, 95% 0.97 to 1.67) compared with low-intensity regions after adjusting for patient and physician characteristics. The overall cardiac catheterization use was 5.2% lower for each increase in GRACE risk decile, and this relationship was observed similarly in all regions. Risk-standardized mortality rates of AMI patients at 3 years were not substantially different between regions.
Although higher-risk patients and those with more appropriate indications may have the most to benefit from an invasive strategy after AMI, we found that higher-invasive regions do not differentiate procedure selection based on the patients' appropriateness or their baseline risks.
我们评估了急性心肌梗死（AMI）后心脏导管插入术的适宜性和基线风险是否根据侵入性治疗的区域强度而有所不同，以及AMI死亡率是否根据侵入性强度区域而有所不同。
在美国，AMI后心脏侵入性手术的使用存在显著的区域差异。
我们对1998年至2001年间因AMI住院的44639名医疗保险按服务收费受益人进行了分析。侵入性手术强度根据医疗保险参保者的总体心脏导管插入率确定。心脏导管插入术的适宜性由美国心脏病学会/美国心脏协会分类确定，基线风险使用GRACE（急性冠状动脉事件全球注册）风险评分进行估计。该研究的主要结局是入院后60天内心脏导管插入术的使用情况和3年死亡率。
在调整患者和医生特征后，与低强度区域相比，高强度区域更有可能对I类患者（适宜）（相对风险1.38，95%置信区间[CI]1.27至1.48）、II类患者（不明确）（相对风险1.42，95%CI 1.31至1.53）和III类患者（不适宜）（相对风险1.29，95%CI 0.97至1.67）进行心脏导管插入术。GRACE风险十分位数每增加一级，总体心脏导管插入术的使用率就降低5.2%，并且在所有区域都观察到了类似的关系。各区域AMI患者3年的风险标准化死亡率没有实质性差异。
尽管高风险患者和那些有更适宜指征的患者可能最能从AMI后的侵入性策略中获益，但我们发现，侵入性较高的区域并没有根据患者的适宜性或基线风险来区分手术选择。
