Valle Javier A, Glorioso Thomas J, Maddox Thomas M, Armstrong Ehrin J, Waldo Stephen W, Bradley Steven M, Ho P Michael
Cardiology Section, Veterans Affairs Rocky Mountain Regional Medical Center, Aurora (J.A.V., T.J.G., T.M.M., E.J.A., S.W.W., S.M.B., P.M.H.).
Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., E.J.A., S.W.W., P.M.H.).
Circ Cardiovasc Qual Outcomes. 2018 Sep;11(9):e004623. doi: 10.1161/CIRCOUTCOMES.118.004623.
Background In regional healthcare referral networks, specialty care is provided at a few sites within the network, with patients referred there for management. This model may increase access to specialized care but also increases the distance that patients travel to receive such care, with unknown effects on longitudinal outcomes. The Veterans Administration uses such regional models for percutaneous coronary intervention (PCI). The impact of patient distance from specialty centers on longitudinal outcomes after receipt of specialized care is understudied and may carry implications for care delivery models. Methods and Results We identified 31 483 patients undergoing PCI at 64 Veterans Administration sites between 2008 to 2012, and assessed the relationship between quintile (Qn) of patient distance from PCI center and all-cause death or myocardial infarction within a year of PCI. Secondary analyses investigated interactions between patient distance and PCI presentation, urgency, and Medicare eligibility on the primary outcome. Median distance to PCI site was 48 miles (interquartile range, 17-110). After adjustment, increasing distance from PCI center was not associated with higher risk of 1-year death or myocardial infarction (with Qn1 as reference, Qn2: odds ratio, 1.02 [95% simultaneous CI, 0.84-1.25]; Qn3: 1.06 [95% simultaneous CI, 0.87-1.30]; Qn4: 0.92 [95% simultaneous CI, 0.75-1.14]; Qn5: 0.97 [95% simultaneous CI, 0.78-1.20]). Stratifying the cohort by acute coronary syndrome presentation, urgency of PCI, and by eligibility for Medicare did not find an association between distance and outcome. Conclusions In this cohort of US veterans, 50% traveled 48 miles or longer to undergo PCI, and 25% traveled >110 miles. Despite this wide range of distances traveled, there was no association between patient distance to PCI center and subsequent outcomes of death or myocardial infarction at 1 year. These findings suggest that regional referral networks may represent viable models for PCI care delivery.
背景 在区域医疗转诊网络中，专科护理在网络内的少数几个地点提供，患者被转诊到那里接受治疗。这种模式可能会增加获得专科护理的机会，但也会增加患者接受此类护理的行程距离，对长期预后的影响尚不清楚。退伍军人事务部使用这种区域模式进行经皮冠状动脉介入治疗（PCI）。患者与专科中心的距离对接受专科护理后的长期预后的影响研究不足，可能对护理模式产生影响。
方法与结果 我们确定了2008年至2012年间在64个退伍军人事务部站点接受PCI的31483例患者，并评估了患者与PCI中心距离的五分位数（Qn）与PCI后一年内全因死亡或心肌梗死之间的关系。二次分析调查了患者距离与PCI表现、紧急程度以及医疗保险资格对主要结局的相互作用。到PCI站点的中位距离为48英里（四分位间距，17 - 110）。调整后，与PCI中心距离的增加与1年死亡或心肌梗死的较高风险无关（以Qn1为参照，Qn2：比值比，1.02 [95%同时置信区间，0.84 - 1.25]；Qn3：1.06 [95%同时置信区间，0.87 - 1.30]；Qn4：0.92 [95%同时置信区间，0.75 - 1.14]；Qn5：0.97 [95%同时置信区间，0.78 - 1.20]）。根据急性冠状动脉综合征表现、PCI紧急程度以及医疗保险资格对队列进行分层，未发现距离与结局之间存在关联。
结论 在这组美国退伍军人中，50%的人前往接受PCI的行程为48英里或更长，25%的人行程超过110英里。尽管行程距离范围很广，但患者与PCI中心的距离与1年后的死亡或心肌梗死后续结局之间没有关联。这些发现表明，区域转诊网络可能是PCI护理模式的可行模式。
