Lin Grace A, Dudley R Adams, Lucas F L, Malenka David J, Vittinghoff Eric, Redberg Rita F
Division of General Internal Medicine, University of California, San Francisco, USA.
JAMA. 2008 Oct 15;300(15):1765-73. doi: 10.1001/jama.300.15.1765.
Guidelines call for documenting ischemia in patients with stable coronary artery disease prior to elective percutaneous coronary intervention (PCI).
To determine the frequency and predictors of stress testing prior to elective PCI in a Medicare population.
DESIGN, SETTING, AND PATIENTS: Retrospective, observational cohort study using claims data from a 20% random sample of 2004 Medicare fee-for-service beneficiaries aged 65 years or older who had an elective PCI (N = 23 887).
Percentage of patients who underwent stress testing within 90 days prior to elective PCI; variation in stress testing prior to PCI across 306 hospital referral regions; patient, physician, and hospital characteristics that predicted the appropriate use of stress testing prior to elective PCI.
In the United States, 44.5% (n = 10 629) of patients underwent stress testing within the 90 days prior to elective PCI. There was wide regional variation among the hospital referral regions with stress test rates ranging from 22.1% to 70.6% (national mean, 44.5%; interquartile range, 39.0%-50.9%). Female sex (adjusted odds ratio [AOR], 0.91; 95% confidence interval [CI], 0.86-0.97), age of 85 years or older (AOR, 0.83; 95% CI, 0.72-0.95), a history of congestive heart failure (AOR, 0.85; 95% CI, 0.79-0.92), and prior cardiac catheterization (AOR, 0.45; 95% CI, 0.38-0.54) were associated with a decreased likelihood of prior stress testing. A history of chest pain (AOR, 1.28; 95% CI, 1.09-1.54) and black race (AOR, 1.26; 95% CI, 1.09-1.46) increased the likelihood of stress testing prior to PCI. Patients treated by physicians performing 150 or more PCIs per year were less likely to have stress testing prior to PCI (AOR, 0.84; 95% CI, 0.77-0.93). No hospital characteristics were associated with receipt of stress testing.
The majority of Medicare patients with stable coronary artery disease do not have documentation of ischemia by noninvasive testing prior to elective PCI.
指南要求在择期经皮冠状动脉介入治疗（PCI）前记录稳定型冠状动脉疾病患者的缺血情况。
确定医疗保险人群中择期PCI前进行负荷试验的频率及预测因素。
设计、设置和患者：一项回顾性观察队列研究，使用2004年20%随机抽样的65岁及以上有择期PCI的医疗保险按服务收费受益人的索赔数据（N = 23887）。
择期PCI前90天内进行负荷试验的患者百分比；306个医院转诊区域PCI前负荷试验的差异；预测择期PCI前负荷试验合理使用的患者、医生和医院特征。
在美国，44.5%（n = 10629）的患者在择期PCI前90天内进行了负荷试验。医院转诊区域之间存在很大的地区差异，负荷试验率从22.1%到70.6%不等（全国平均水平为44.5%；四分位间距为39.0% - 50.9%）。女性（调整优势比[AOR]，0.91；95%置信区间[CI]，0.86 - 0.97）、85岁及以上（AOR，0.83；95% CI，0.72 - 0.95）、有充血性心力衰竭病史（AOR，0.85；95% CI，0.79 - 0.92）和既往心脏导管插入术（AOR，0.45；95% CI，0.38 - 0.54）与PCI前进行负荷试验的可能性降低相关。胸痛病史（AOR，1.28；95% CI，1.09 - 1.54）和黑人种族（AOR，1.26；95% CI，1.09 - 1.46）增加了PCI前进行负荷试验的可能性。每年进行150次或更多PCI的医生治疗的患者在PCI前进行负荷试验的可能性较小（AOR，0.84；95% CI，0.77 - 0.93）。没有医院特征与接受负荷试验相关。
大多数患有稳定型冠状动脉疾病的医疗保险患者在择期PCI前没有通过无创检测记录缺血情况。
