Parkash Ratika, Wightman Howard, Miles Graham, Sapp John L, Gardner Martin, Gray Chris, Brownell Brenda, Giddens Karen, Rajda Miroslaw
QE II Health Sciences Centre, Halifax, Nova Scotia, Canada.
Valley Regional Hospital, Kentville, Nova Scotia, Canada.
Can J Cardiol. 2017 Apr;33(4):437-442. doi: 10.1016/j.cjca.2016.10.020. Epub 2017 Jan 17.
Implantable cardioverter defibrillators (ICDs) have shown benefit in reducing mortality in patients with heart failure, after myocardial infarction, and those with reduced ejection fraction. We sought to explore the use of this therapy in specialized heart function clinics, in rural and urban locations.
This was a retrospective cohort study performed in 3 specialized heart function clinics in Nova Scotia, 2 of which were in rural locations. All patients with an initial left ventricular ejection fraction ≤ 35% were included from 2006 to 2011. Rates of referral, ICD implantation, and mortality were compared between urban and rural groups.
There were 922 patients included in the study; 636 patients in the urban clinic, 286 in the rural locations. Referral rates were higher in the urban clinic compared with the rural locations (80.4% vs 68.3%; P = 0.024). Refusal rates for referral were higher in the rural locations (13.7% vs 2.1%; P < 0.0001). Higher referral rates were associated with urban location (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.01-3.26; P = 0.047), and younger age (OR, 0.96; 95% CI, 0.93-0.99; P = 0.003); lower referral rates for women was observed (OR, 2.29; 95% CI, 1.13-4.63; P = 0.021). Mortality was significantly associated with older age, lack of referral, presence of comorbidities (renal failure, diabetes, peripheral vascular disease) and a rural location.
Specialized heart function clinics have a high rate of appropriate referral for primary prevention ICDs, but referral rates for this life-saving therapy remain lower in rural jurisdictions. This disparity in access to care is associated with increased mortality and might require particular attention to prevent unnecessary deaths.
植入式心脏复律除颤器（ICD）已显示出在降低心力衰竭患者、心肌梗死后患者以及射血分数降低患者的死亡率方面具有益处。我们试图探讨在农村和城市地区的专业心脏功能诊所中使用这种治疗方法。
这是一项在新斯科舍省的3家专业心脏功能诊所进行的回顾性队列研究，其中2家位于农村地区。纳入了2006年至2011年所有初始左心室射血分数≤35%的患者。比较了城市和农村组之间的转诊率、ICD植入率和死亡率。
该研究共纳入922例患者；城市诊所636例，农村地区286例。城市诊所的转诊率高于农村地区（80.4%对68.3%；P = 0.024）。农村地区转诊拒绝率更高（13.7%对2.1%；P < 0.0001）。较高的转诊率与城市地区相关（优势比[OR]，1.81；95%置信区间[CI]，1.01 - 3.26；P = 0.047），以及较年轻的年龄（OR，0.96；95%CI，0.93 - 0.99；P = 0.003）；观察到女性转诊率较低（OR，2.29；95%CI，1.13 - 4.63；P = 0.021）。死亡率与年龄较大、未转诊、存在合并症（肾衰竭、糖尿病、外周血管疾病）以及农村地区显著相关。
专业心脏功能诊所对一级预防ICD的适当转诊率较高，但在农村地区，这种挽救生命的治疗方法的转诊率仍然较低。这种获得医疗服务的差异与死亡率增加相关，可能需要特别关注以防止不必要的死亡。
