Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL USA ; Malcom Randall Veterans Affairs Medical Center, Gainesville, FL USA.
Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL USA.
Mil Med Res. 2016 Jul 25;3:22. doi: 10.1186/s40779-016-0090-5. eCollection 2016.
Cardiac troponin assays have improved the ability to detect myocardial damage. However, ascertaining whether troponin elevation is due to myocardial infarction (MI) or secondary to another process can be challenging. Our aim is to evaluate provider-level variation in the diagnosis of MI and the use of invasive coronary angiography (ICA) among patients with undifferentiated elevations in cardiac troponin.
We analyzed data from all patients with elevated troponin levels in a single Veterans Affairs (VA) Medical Center between 2006 and 2007. One of several cardiologists prospectively evaluated each patient's presentation and course of care. We compared the frequency of MI diagnosis and ICA use between physicians using univariate odds ratios (OR).
Among 761 patients, 34.0 % were diagnosed with MI and 25.9 % underwent ICA. The unadjusted rates of MI (23.9 to 56.7 %, P = 0.02) and ICA (17.3 to 73.3 %, P < 0.001) differed between physicians. Comparing the patient cohorts for each physician, baseline characteristics were similar except for chest pain. In multivariate regression, factors associated with the use of cardiac ICA included an abnormal electrocardiograph (ECG) (OR = 1.89, P = 0.014), level of troponin (OR = 1.71, P = 0.004), chest pain (OR = 8.60, P < 0.001), and care by non-VA physicians (OR = 4.45, P = 0.006). One physician had a lower ICA use (OR = 0.56, P = 0.017). In multivariate regression of MI, no physician-level variation was observed.
Among patients with elevated troponin, the likelihood of being diagnosed with MI and undergoing ICA is dependent on their clinical presentation. After adjustment, physician-level variation in care was observed for the use of ICA, but not for the diagnosis of MI.
心肌肌钙蛋白检测提高了检测心肌损伤的能力。然而，确定肌钙蛋白升高是由于心肌梗死（MI）还是继发于其他过程可能具有挑战性。我们的目的是评估在 VA 医疗中心就诊的心肌肌钙蛋白水平升高的患者中，医生在 MI 诊断和有创性冠状动脉造影（ICA）应用方面的差异。
我们分析了 2006 年至 2007 年间 VA 医疗中心所有心肌肌钙蛋白升高的患者数据。几位心脏病专家前瞻性地评估了每位患者的表现和治疗过程。我们使用单变量优势比（OR）比较了医生之间 MI 诊断和 ICA 使用的频率。
在 761 名患者中，34.0%被诊断为 MI，25.9%接受了 ICA。未调整的 MI 发生率（23.9%至 56.7%，P=0.02）和 ICA 使用率（17.3%至 73.3%，P<0.001）在医生之间有所不同。比较每位医生的患者队列，除了胸痛外，基线特征相似。多变量回归显示，与使用心脏 ICA 相关的因素包括异常心电图（ECG）（OR=1.89，P=0.014）、肌钙蛋白水平（OR=1.71，P=0.004）、胸痛（OR=8.60，P<0.001）和非 VA 医生治疗（OR=4.45，P=0.006）。一位医生的 ICA 使用率较低（OR=0.56，P=0.017）。在 MI 的多变量回归中，未观察到医生水平的差异。
在心肌肌钙蛋白升高的患者中，被诊断为 MI 和接受 ICA 的可能性取决于他们的临床表现。调整后，观察到医生在 ICA 应用方面存在差异，但在 MI 诊断方面没有差异。
