Panush R S, Carias K, Kramer N, Rosenstein E D
Arthritis and Rheumatic Disease Center and Division of Rheumatology, Department of Medicine. Saint Bambas Medical Center, Livingston, New Jersey.
J Clin Rheumatol. 1995 Apr;1(2):74-80.
Certain health care reform proposals emphasize "primary" rather than specialty care, so it is important to document whether these changes might affect patients with rheumatic diseases. We therefore assessed outcome and costs of patients who were hospitalized with acute arthritis, comparing management by rheumatologists with nonrheumatologists. We reviewed charts retrospectively from 1991 to 1993 at our community medical center. Twenty patients with acute arthritis were managed by rheumatologists and 35 were managed by nonrheumatologists. Demographic, clinical, and rheumatologic features of patients were comparable.Rheumatologists ordered joint radiographs (65%) and performed diagnostic arthrocentesis (75%) significantly more often than nonrheumatologists (31 and 34%, respectively; p < 0.05). Rheumatologists' initial recorded diagnostic impressions were usually confirmed at discharge, whereas nonrheumatologists' more often were not (p < 0.05). Rheumatologists established definite diagnoses by American College of Rheumatology criteria significantly more often (75%) than nonrheumatologists (34%;p < 0.05). Nonrheumatologists selected antibiotics, systemic corticosteroids, nonsteroidal anti-inflammatory drugs, and allopurinol more often and intra-articular steroids (p < 0.05) and adrenocorticotropic hormone less often for a similar case mix than rheumatologists. Rheumatologists' clinical evaluations (p < 0.001), selection of diagnostic studies (p < 0.001), and therapeutic decisions (p < 0.005) were significantly more complete. Trends strongly favored rheumatologists' patients improving more rapidly (3.5 vs. 6.6 days; p = 0.06) and being hospitalized for shorter stays (7.4 vs. 14.7 days; p = 0.08) and favored rheumatologists' patients as managed at considerably less hospital cost ($8756 vs. $14,750).These limited observations suggest caution about equating nonspecialty with rheumatologic care and are consistent with suggestions that, at least for certain patients and as defined by our criteria above, rheumatologists offer more complete evaluation, more accurate diagnosis, more rational therapy, and better clinical outcome at lower cost than do nonrheumatologists.
某些医疗保健改革提议强调“初级”护理而非专科护理，因此，记录这些变化是否会影响风湿病患者很重要。为此，我们评估了因急性关节炎住院患者的治疗结果和费用，比较了风湿病专科医生和非风湿病专科医生的管理情况。我们回顾了1991年至1993年我们社区医疗中心的病历。20例急性关节炎患者由风湿病专科医生管理，35例由非风湿病专科医生管理。患者的人口统计学、临床和风湿病学特征具有可比性。风湿病专科医生开具关节X光片（65%）和进行诊断性关节穿刺术（75%）的频率显著高于非风湿病专科医生（分别为31%和34%；p<0.05）。风湿病专科医生最初记录的诊断印象在出院时通常得到确认，而非风湿病专科医生的诊断印象则更多未得到确认（p<0.05）。按照美国风湿病学会标准，风湿病专科医生明确诊断的比例（75%）显著高于非风湿病专科医生（34%；p<0.05）。对于类似的病例组合，非风湿病专科医生更常选用抗生素、全身性皮质类固醇、非甾体抗炎药和别嘌醇，而选用关节内类固醇（p<0.05）和促肾上腺皮质激素的频率低于风湿病专科医生。风湿病专科医生的临床评估（p<0.001）、诊断检查的选择（p<0.001）和治疗决策（p<0.005）明显更完善。趋势强烈表明，由风湿病专科医生管理的患者康复更快（3.5天对6.6天；p=0.06），住院时间更短（7.4天对14.7天；p=0.08），而且由风湿病专科医生管理的患者住院费用要低得多（8756美元对14750美元）。这些有限的观察结果表明，对于将非专科护理等同于风湿病护理需谨慎，并且与以下观点一致，即至少对于某些患者以及根据我们上述标准界定的患者，与非风湿病专科医生相比，风湿病专科医生能以更低的成本提供更全面的评估、更准确的诊断、更合理的治疗以及更好的临床结果。
