美国医疗保险受益人群中合并与不合并慢性肾脏病患者的心脏应激试验比较利用和时间趋势。
Comparative Utilization and Temporal Trends in Cardiac Stress Testing in U.S. Medicare Beneficiaries With and Without Chronic Kidney Disease.
机构信息
Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota; Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota.
Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota.
出版信息
JACC Cardiovasc Imaging. 2019 Aug;12(8 Pt 1):1420-1426. doi: 10.1016/j.jcmg.2018.04.012. Epub 2018 Jun 13.
OBJECTIVES
The authors aimed to analyze temporal trends in cardiac stress testing in U.S. Medicare beneficiaries from 2008 to 2012, types of stress testing, and comparative utilization related to the presence and severity of chronic kidney disease (CKD).
BACKGROUND
A long-held perception depicts patients with CKD as being treated less intensively for cardiovascular disease than nonrenal patients. We wondered whether use of diagnostic testing for ischemic heart disease is affected by the presence of CKD.
METHODS
Using the 20% Medicare sample, we assembled yearly cohorts of Medicare beneficiaries (∼4,500,000 per year) from 2008 to 2012. Beneficiaries 66 years or older undergoing a first cardiac stress test, with no previous history of coronary revascularization and no acute coronary syndrome within 60 days, were identified, as was the type of stress test. We analyzed temporal trends and compared testing rates related to CKD stage versus no CKD. A Poisson regression model estimated the likelihood of stress testing in 2012 by CKD stage, adjusted for demographic characteristics and comorbid conditions.
RESULTS
Approximately 480,000 older patients (∼29,000 with CKD) underwent stress tests in 2008, progressively declining to ∼400,000 in 2012 (∼38,000 with CKD). In 2008 to 2012, 78% to 80% of all stress testing in non-CKD patients used nuclear imaging, as did 87% to 88% in CKD patients. Rates of stress testing declined progressively for non-CKD and CKD patients in 2008 to 2012: 11.5 to 9.4 per 100 patient-years and 16.8 to 13.4 per 100 patient-years, respectively. The adjusted Poisson model, with non-CKD as the reference, showed an increasing likelihood of stress testing with worsening CKD: incidence rate ratio 1.01 for stages 1 to 2 (p = NS), 1.05 for stage 3 (p < 0.0001), 1.01 for stage 4 (p = NS), 1.04 for stage 5 nondialysis (p = NS), and 1.15 for stage 5 dialysis (p < 0.0001).
CONCLUSIONS
Overall rates of cardiac stress testing (over three-fourths using nuclear imaging) declined in 2008 to 2012 among Medicare beneficiaries 66 years or older but were consistently higher for CKD than for non-CKD patients. The effect of screening algorithms for transplant candidates was unknown. Our data refute underutilization of cardiac stress testing in CKD patients.
目的
作者旨在分析 2008 年至 2012 年间美国医疗保险受益人的心脏压力测试的时间趋势、压力测试的类型，以及与慢性肾脏病（CKD）的存在和严重程度相关的比较利用情况。
背景
长期以来的一种观点认为，CKD 患者的心血管疾病治疗强度低于非肾患者。我们想知道，缺血性心脏病诊断检测的使用是否受 CKD 存在的影响。
方法
使用 Medicare 20%的样本，我们从 2008 年至 2012 年每年收集 Medicare 受益人的队列（每年约 450 万）。确定年龄在 66 岁或以上、首次进行心脏压力测试且无冠状动脉血运重建史且在 60 天内无急性冠状动脉综合征的患者，并确定压力测试的类型。我们分析了时间趋势，并比较了与 CKD 分期相关的测试率与无 CKD 的测试率。泊松回归模型估计了 2012 年 CKD 分期对压力测试的可能性，调整了人口统计学特征和合并症。
结果
2008 年约有 48 万老年患者（约 29000 例有 CKD）接受了压力测试，到 2012 年逐渐下降至约 40 万（约 38000 例有 CKD）。在 2008 年至 2012 年期间，非 CKD 患者中约 78%至 80%的所有压力测试使用核成像，CKD 患者中约 87%至 88%使用核成像。2008 年至 2012 年期间，非 CKD 和 CKD 患者的压力测试率呈逐渐下降趋势：每 100 名患者年分别为 11.5 至 9.4 和 16.8 至 13.4。非 CKD 作为参考的调整泊松模型显示，随着 CKD 的恶化，压力测试的可能性逐渐增加：1 至 2 期的发病率比为 1.01（p=NS），3 期为 1.05（p<0.0001），4 期为 1.01（p=NS），5 期非透析为 1.04（p=NS），5 期透析为 1.15（p<0.0001）。
结论
2008 年至 2012 年间，66 岁及以上的 Medicare 受益人的心脏压力测试总体比率（超过四分之三使用核成像）下降，但 CKD 患者的压力测试率始终高于非 CKD 患者。用于移植候选者的筛选算法的效果尚不清楚。我们的数据反驳了 CKD 患者心脏压力测试利用不足的观点。
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