Gaspoz J M, Lee T H, Weinstein M C, Cook E F, Goldman P, Komaroff A L, Goldman L
Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115.
J Am Coll Cardiol. 1994 Nov 1;24(5):1249-59. doi: 10.1016/0735-1097(94)90106-6.
This study attempted to determine the safety and costs of a new short-stay unit for low risk patients who may be admitted to a hospital to rule out myocardial infarction or ischemia.
One strategy to reduce the costs of ruling out acute myocardial infarction in low risk patients is to develop alternatives to coronary care units.
The short-term and 6-month clinical outcomes and costs for 592 patients admitted to a short-stay coronary observation unit at Brigham and Women's Hospital with a low (< or = 10%) probability of acute myocardial infarction were compared with those for 924 consecutive comparison patients who were eligible for the same unit but were admitted to other hospital settings or discharged home. Actual costs were calculated using detailed cost-accounting methods that incorporated nursing intensity weights.
The rate of major complications, recurrent myocardial infarction or cardiac death during 6 months after the initial presentation of the 592 patients admitted to the coronary observation unit was similar to that of the 924 comparison patients before and after adjustment for clinical factors influencing triage and initial diagnoses (adjusted relative risk 0.86, 95% confidence interval 0.49 to 1.53). Their median total costs (25th, 75th percentile) at 6 months ($1,927; 1,455, 3,650) were significantly lower than for comparison patients admitted to the wards $4,712; 1,868, 11,187), to stepdown or intermediate care units ($4,031; 2,069, 9,169) or to the coronary care unit ($9,201; 3,171, 20,011) but were higher than for comparison patients discharged home from the emergency department ($403; 403,927) before and after the same adjustments (all adjusted p < 0.0001).
These data suggest that the coronary observation unit may be a safe and cost-saving alternative to current triage strategies for patients with a low risk of acute myocardial infarction admitted from the emergency department. Its replication in other hospitals should be tested.
本研究试图确定一个新的短期留观单元对于可能因排除心肌梗死或缺血而入院的低风险患者的安全性和成本。
降低低风险患者排除急性心肌梗死成本的一种策略是开发冠心病监护病房的替代方案。
将592例入住布莱根妇女医院短期冠心病观察单元且急性心肌梗死可能性低（≤10%）的患者的短期和6个月临床结局及成本，与924例符合该单元收治条件但入住其他医院科室或出院回家的连续对照患者进行比较。实际成本采用纳入护理强度权重的详细成本核算方法计算。
入住冠心病观察单元的592例患者在初次就诊后6个月内的主要并发症、复发性心肌梗死或心源性死亡发生率，与924例对照患者在调整影响分诊和初始诊断的临床因素前后相似（调整后相对风险0.86，95%置信区间0.49至1.53）。他们6个月时的中位总成本（第25、75百分位数）（1927美元；1455，3650美元）显著低于入住病房的对照患者（4712美元；1868，11187美元）、入住降级或中级护理单元的对照患者（4031美元；2069，9169美元）或入住冠心病监护病房的对照患者（9201美元；3171，20011美元），但高于经相同调整后从急诊科出院回家的对照患者（403美元；403，927美元）（所有调整后p<0.0001）。
这些数据表明，对于从急诊科入院的急性心肌梗死低风险患者，冠心病观察单元可能是当前分诊策略的一种安全且节省成本的替代方案。应在其他医院测试其推广应用情况。
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