Bainey Kevin R, Kaul Padma, Armstrong Paul W, Savu Anamaria, Westerhout Cynthia M, Norris Colleen M, Brass Neil, Traboulsi Dean, O'Neill Blair, Nagendran Jayan, Ali Imtiaz, Knudtson Merril, Welsh Robert C
Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
Int J Cardiol. 2017 Aug 15;241:70-75. doi: 10.1016/j.ijcard.2017.04.109. Epub 2017 May 5.
We examined variation in hospital treatment and its relationship to clinical outcome in a large population-based cohort of ACS patients within a single payer-government funded health care system.
Patients hospitalized in 106 hospitals in Alberta, Canada with a primary diagnosis of ACS were included (July 1, 2010-March 31, 2013) with comparisons made across the three cardiac catheterization-capable hospitals (Sites A-C). Cox proportional-hazard regression models were used to examine the multivariable-adjusted association between site and 1-year death or repeat cardiovascular (CV) hospitalization (primary endpoint).
Of 14,155 patients, 1938 (13.7%) were admitted to a community hospital without transfer to an invasive hospital (10.7% in-hospital death). The remaining were admitted (n=4514, 36.9%) or transferred (n=7703, 63.1%) to an invasive hospital (A:5480; B:3621; C:3116) where 11,247 (92.1%) underwent catheterization. Comorbidities and angiographic disease burden differed across sites. Variation in 30-day revascularization (PCI: 71.3%, 72.0%, 68.7%, p<0.001; CABG: 6.2%, 6.4%, 9.3%, p<0.001) and drug-eluting stent use for PCI (24.3%, 54.6%, 50.5%, p<0.001) were observed. After adjustment for patient demographics and comorbidities, variation in rates of 1-year death or CV hospitalization was observed among those with 30-day revascularization (p(interaction)<0.001; B versus A: HR 0.78, 95%CI 0.66-0.91; C versus A: HR 0.77, 95%CI 0.65-0.91; B versus C: HR 1.01, 95%CI 0.84-1.21).
Despite a government funded health system, we have shown variation in hospital treatment exists. Following adjustment hospital site was associated with differences in clinical outcome within 1year. Hence, further efforts may be warranted to help address potential disparities in ACS care.
我们在一个单一支付方——政府资助的医疗保健系统中，对一大群以社区为基础的急性冠状动脉综合征（ACS）患者的医院治疗差异及其与临床结局的关系进行了研究。
纳入在加拿大艾伯塔省106家医院住院且主要诊断为ACS的患者（2010年7月1日至2013年3月31日），并对三家具备心脏导管插入术能力的医院（A - C站点）进行比较。采用Cox比例风险回归模型来检验站点与1年死亡或再次心血管（CV）住院（主要终点）之间的多变量调整关联。
在14,155名患者中，1938名（13.7%）入住社区医院且未转至有创治疗医院（院内死亡率为10.7%）。其余患者被收治（n = 4514，36.9%）或转至有创治疗医院（n = 7703，63.1%）（A：5480；B：3621；C：3116），其中11,247名（92.1%）接受了导管插入术。各站点的合并症和血管造影疾病负担有所不同。观察到30天血运重建存在差异（经皮冠状动脉介入治疗（PCI）：71.3%、72.0%、68.7%，p < 0.001；冠状动脉旁路移植术（CABG）：6.2%、6.4%、9.3%，p < 0.001）以及PCI中药物洗脱支架的使用情况（24.3%、54.6%、50.5%，p < 0.001）。在对患者人口统计学和合并症进行调整后，观察到30天接受血运重建的患者中1年死亡或CV住院率存在差异（p（交互作用）< 0.001；B与A相比：风险比（HR）0.78，95%置信区间（CI）0.66 - 0.91；C与A相比：HR 0.77，95%CI 0.65 - 0.91；B与C相比：HR 1.01，95%CI 0.84 - 1.21）。
尽管是政府资助的医疗系统，但我们已表明医院治疗存在差异。调整后，医院站点与1年内的临床结局差异相关。因此，可能需要进一步努力以帮助解决ACS治疗中潜在的差异问题。
