Pulmonary and Critical Care Medicine Division at Intermountain Medical Center and the University of Utah, Salt Lake City, UT, USA.
Ann Emerg Med. 2012 Jan;59(1):35-41. doi: 10.1016/j.annemergmed.2011.07.032. Epub 2011 Sep 9.
We examine variability among emergency physicians in rate of hospitalization for patients with pneumonia and the effect of variability on clinical outcomes.
We studied 2,069 LDS Hospital emergency department (ED) patients with community-acquired pneumonia who were aged 18 years or older during 1996 to 2006, identified by International Classification of Diseases, Ninth Revision coding and compatible chest radiographs. We extracted vital signs, laboratory and radiographic results, hospitalization, and outcomes from the electronic medical record. We defined "low severity" as PaO(2)/FiO(2) ratio greater than or equal to 280 mm Hg, predicted mortality less than 5% by an electronic version of CURB-65 that uses continuous and weighted elements (eCURB), and less than 3 Infectious Disease Society of America-American Thoracic Society 2007 severe pneumonia minor criteria. We adjusted hospitalization decisions and outcomes for illness severity and patient demographics.
Initial hospitalization rate was 58%; 10.7% of patients initially treated as outpatients were secondarily hospitalized within 7 days. Median age of admitted patients was 63 years; median eCURB predicted mortality was 2.65% (mean 6.8%) versus 46 years and 0.93% for outpatients. The 18 emergency physicians (average age 44.9 [standard deviation 7.6] years; years in practice 8.4 [standard deviation 6.9]) objectively calculated and documented illness severity in 2.7% of patients. Observed 30-day mortality for inpatients was 6.8% (outpatient mortality 0.34%) and decreased over time. Individual physician admission rates ranged from 38% to 79%, with variability not explained by illness severity, time of day, day of week, resident care in conjunction with an attending physician, or patient or physician demographics. Higher hospitalization rates were not associated with reduced mortality or fewer secondary hospital admissions.
We observed a 2-fold difference in pneumonia hospitalization rates among emergency physicians, unexplained by objective data.
我们考察了急诊医师对肺炎患者住院率的差异，以及这种差异对临床结果的影响。
我们研究了 1996 年至 2006 年间在 LDS 医院急诊科就诊的 2069 例年龄在 18 岁及以上的社区获得性肺炎患者，这些患者的诊断通过国际疾病分类，第九修订版编码和相符的胸部 X 线片确定。我们从电子病历中提取生命体征、实验室和影像学结果、住院情况和结果。我们将“低严重度”定义为 PaO(2)/FiO(2) 比值大于或等于 280mmHg，使用连续和加权元素的电子版本 CURB-65（eCURB）预测死亡率小于 5%，以及不符合 2007 年美国传染病学会-美国胸科学会严重肺炎次要标准的小于 3 项。我们调整了住院决策和结果，以考虑疾病严重程度和患者人口统计学特征。
初始住院率为 58%；10.7%的初始门诊治疗患者在 7 天内再次住院。住院患者的中位年龄为 63 岁；中位 eCURB 预测死亡率为 2.65%（平均 6.8%），而门诊患者的中位年龄为 46 岁，eCURB 预测死亡率为 0.93%。18 名急诊医师（平均年龄 44.9[标准差 7.6]岁；行医年限 8.4[标准差 6.9]年）客观地计算和记录了 2.7%的患者的疾病严重程度。住院患者 30 天死亡率为 6.8%（门诊患者死亡率为 0.34%），且随时间推移而降低。个别医师的入院率从 38%到 79%不等，这种差异不能用疾病严重程度、一天中的时间、一周中的天数、住院医师与主治医生一起护理、患者或医生的人口统计学特征来解释。较高的住院率与死亡率降低或较少的二次住院无关。
我们观察到急诊医师对肺炎患者的住院率存在 2 倍的差异，这种差异无法用客观数据解释。
