Division of General Medicine, University of Iowa Carver College of Medicine, Iowa City, 52246, USA.
Am Heart J. 2012 Feb;163(2):222-9.e1. doi: 10.1016/j.ahj.2011.10.010.
In the United States, there continues to be debate about whether certain types of hospitals deliver improved patient outcomes. We sought to assess the association between hospital organizational characteristics and in-hospital outcomes for percutaneous coronary intervention (PCI).
Retrospective analysis of 2004 to 2007 data for 694 US hospitals participating in the CathPCI Registry(®). Our analysis focused on 1,113,554 patients who underwent PCI in 471 not-for-profit (NFP) hospitals, 131 major teaching hospitals, 79 for-profit (FP) hospitals, and 13 physician-owned specialty hospitals. Outcomes included in-hospital mortality, stroke, bleeding, vascular injury, and a composite representing one or more of the individual complications. We used the current CathPCI Registry mortality risk model to calculate risk-standardized mortality ratios (RSMRs) for each category of hospital and compared hospital groupings for all patients in aggregate and in subgroups stratified by patients' indications for PCI.
Patients treated in major teaching hospitals were younger, whereas FP hospitals performed a greater proportion of PCI for patients with ST-elevation myocardial infarction (P < .0001). Specialty hospitals treated patients with less acuity, including a lower proportion of patients with ST-elevation myocardial infarction. In unadjusted analyses, specialty hospitals had significantly lower rates of all adverse outcomes compared with NFP, teaching, and FP hospitals including in-hospital mortality (0.7%, 1.2%, 1.4%, and 1.4%, respectively; P < .001) and the composite end point (2.4%, 4.1%, 4.6%, and 4.3%, respectively; P < .001). In adjusted analyses, RSMR was significantly lower for specialty hospitals when compared with the other 3 groups for all patients in aggregate (RSMR 1.05%, 1.30%, 1.38%, 1.39%; P < .001); these differences remained clinically significant but were no longer statistically significant in subgroup analyses.
Specialty hospitals appear to have lower rates of most adverse outcomes for PCI. Specialty hospitals may have developed expertise in narrow procedural areas that could be adapted to the larger population of general hospitals.
在美国，关于某些类型的医院是否能提供改善患者预后的服务，仍存在争议。我们试图评估医院组织特征与经皮冠状动脉介入治疗（PCI）院内结局之间的关联。
对参与 CathPCI 注册研究®的 694 家美国医院 2004 年至 2007 年的数据进行回顾性分析。我们的分析集中于在 471 家非营利性（NFP）医院、131 家主要教学医院、79 家营利性（FP）医院和 13 家医生所有的专科医院进行 PCI 的 1113554 例患者。结局包括院内死亡率、卒中和出血、血管损伤以及代表单个并发症之一或多个并发症的复合结局。我们使用当前的 CathPCI 注册死亡率风险模型计算每个医院类别下的风险标准化死亡率比（RSMR），并对所有患者的总体和按患者 PCI 适应证分层的亚组比较医院分组。
在主要教学医院接受治疗的患者年龄较小，而 FP 医院对 ST 段抬高型心肌梗死患者进行的 PCI 比例更高（P<0.0001）。专科医院治疗的患者病情较轻，包括 ST 段抬高型心肌梗死患者的比例较低。在未调整的分析中，专科医院与 NFP、教学和 FP 医院相比，所有不良结局的发生率均显著降低，包括院内死亡率（分别为 0.7%、1.2%、1.4%和 1.4%；P<0.001）和复合终点（分别为 2.4%、4.1%、4.6%和 4.3%；P<0.001）。在调整分析中，与其他 3 组相比，所有患者的总体 RSMR 显著降低（RSMR 1.05%、1.30%、1.38%、1.39%；P<0.001）；这些差异在亚组分析中仍然具有临床意义，但不再具有统计学意义。
专科医院进行 PCI 的大多数不良结局发生率较低。专科医院可能在狭窄的手术领域积累了专业知识，这可以适用于更大比例的综合医院患者。
