特定医疗护理水平与癫痫患者过早死亡风险的相关性。
Association of Levels of Specialized Care With Risk of Premature Mortality in Patients With Epilepsy.
机构信息
O'Brien Institute for Public Health, Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
Hotchkiss Brain Institute, Cumming School of Medicine, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.
出版信息
JAMA Neurol. 2019 Nov 1;76(11):1352-1358. doi: 10.1001/jamaneurol.2019.2268.
IMPORTANCE
Patients with epilepsy are at an elevated risk of premature mortality. Interventions to reduce this risk are crucial.
OBJECTIVE
To determine if the level of care (non-neurologist, neurologist, or comprehensive epilepsy program) is negatively associated with the risk of premature mortality.
DESIGN, SETTING, AND PARTICIPANTS: In this retrospective open cohort study, all adult patients 18 years or older who met the administrative case definition for incident epilepsy in linked databases (Alberta Health Services administrative health data and the Comprehensive Calgary Epilepsy Programme Registry [CEP]) inclusive of the years 2002 to 2016 were followed up until death or loss to follow-up. The final analyses were performed on May 1, 2019.
EXPOSURES
Evaluation by a non-neurologist, neurologist, or epileptologist.
MAIN OUTCOMES AND MEASURES
The outcome was all-cause mortality. We used extended Cox models treating exposure to a neurologist or the CEP as time-varying covariates. Age, sex, socioeconomic deprivation, disease severity, and comorbid burden at index date were modeled as fixed-time coefficients.
RESULTS
A total 23 653 incident cases were identified (annual incidence of 89 per 100 000); the mean age (SD) at index date was 50.8 (19.1) years and 12 158 (50.3%) were women. A total of 14 099 (60%) were not exposed to specialist neurological care, 9554 (40%) received care by a neurologist, and 2054 (9%) received care in the CEP. In total, 4098 deaths (71%) occurred in the nonspecialist setting, 1481 (26%) for those seen by a neurologist, and 176 (3%) for those receiving CEP care. The standardized mortality rate was 7.2% for the entire cohort, 9.4% for those receiving nonspecialist care, 5.6% for those seen by a neurologist, and 2.8% for those seen in the CEP. The hazard ratio (HR) of mortality was lower in those receiving neurologist (HR, 0.85; 95% CI, 0.77-0.93) and CEP (HR, 0.49; 95% CI, 0.38-0.62) care. In multivariable modeling, specialist care, the age at index, and disease severity were retained in the final model of the association between specialist care and mortality.
CONCLUSIONS AND RELEVANCE
Exposure to specialist care is associated with incremental reductions in the hazard of premature mortality. Those referred to a comprehensive epilepsy program received the greatest benefit.
重要性
癫痫患者的过早死亡率较高。降低这种风险的干预措施至关重要。
目的
确定护理水平（非神经科医生、神经科医生或综合癫痫计划）是否与过早死亡的风险呈负相关。
设计、设置和参与者：在这项回顾性开放队列研究中，所有符合 2002 年至 2016 年相关数据库（艾伯塔省卫生服务管理健康数据和卡尔加里综合癫痫计划登记处[CEP]）中癫痫发病行政病例定义的 18 岁及以上的成年患者均接受随访，直至死亡或失访。最终分析于 2019 年 5 月 1 日进行。
暴露
由非神经科医生、神经科医生或癫痫专家评估。
主要结果和测量
结果为全因死亡率。我们使用扩展 Cox 模型，将暴露于神经科医生或 CEP 视为随时间变化的协变量。在指数日期时，年龄、性别、社会经济剥夺程度、疾病严重程度和合并症负担被建模为固定时间系数。
结果
共确定了 23653 例新发病例（每年发病率为 89/10 万）；指数日期的平均年龄（标准差）为 50.8（19.1）岁，12158 例（50.3%）为女性。共有 14099 例（60%）未接受专科神经护理，9554 例（40%）接受神经科医生护理，2054 例（9%）接受 CEP 护理。共有 4098 例死亡（71%）发生在非专科环境中，1481 例（26%）为神经科医生就诊，176 例（3%）为 CEP 就诊。整个队列的标准化死亡率为 7.2%，非专科治疗组为 9.4%，神经科医生就诊组为 5.6%，CEP 就诊组为 2.8%。死亡率的危险比（HR）在接受神经科医生（HR，0.85；95%CI，0.77-0.93）和 CEP（HR，0.49；95%CI，0.38-0.62）治疗的患者中较低。在多变量模型中，专科护理、指数年龄和疾病严重程度保留在专科护理与死亡率关联的最终模型中。
结论和相关性
接受专科护理与过早死亡危险的降低呈增量关系。那些被转介到综合癫痫计划的患者获益最大。
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