Jollis J G, DeLong E R, Peterson E D, Muhlbaier L H, Fortin D F, Califf R M, Mark D B
Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
N Engl J Med. 1996 Dec 19;335(25):1880-7. doi: 10.1056/NEJM199612193352505.
In order to limit costs, health care organizations in the United States are shifting medical care from specialists to primary care physicians. Although primary care physicians provide less resource-intensive care, there is little information concerning the effects of this strategy on outcomes.
We examined mortality according to the specialty of the admitting physician among 8241 Medicare patients who were hospitalized for acute myocardial infarction in four states during a seven-month period in 1992. Proportional-hazards regression models were used to examine survival up to one year after the myocardial infarction. To determine the generalizability of our findings, we also examined insurance claims and survival data for all 220,535 patients for whom there were Medicare claims for hospital care for acute myocardial infarction in 1992.
After adjustment for characteristics of the patients and hospitals, patients who were admitted to the hospital by a cardiologist were 12 percent less likely to die within one year than those admitted by a primary care physician (P<0.001). Cardiologists also had the highest rate of use of cardiac procedures and medications, including medications (such as thrombolytic agents and beta-blockers) that are associated with improved survival.
Health care strategies that shift the care of elderly patients with myocardial infarction from cardiologists to primary care physicians lower rates of use of resources (and potentially lower costs), but they may also cause decreased survival. Additional information is needed to elucidate how primary care physicians and specialists should interact in the care of severely ill patients.
为了控制成本，美国的医疗保健机构正将医疗服务从专科医生转向初级保健医生。尽管初级保健医生提供的医疗服务资源密集度较低，但关于这一策略对治疗结果的影响，几乎没有相关信息。
我们调查了1992年四个州8241名因急性心肌梗死住院的医疗保险患者中，根据收治医生的专业划分的死亡率情况。使用比例风险回归模型来研究心肌梗死后长达一年的生存率。为了确定我们研究结果的普遍性，我们还研究了1992年有医疗保险急性心肌梗死住院索赔记录的所有220535名患者的保险索赔和生存数据。
在对患者和医院的特征进行调整后，由心脏病专家收治入院的患者在一年内死亡的可能性比由初级保健医生收治的患者低12%（P<0.001）。心脏病专家使用心脏手术和药物的比例也最高，包括与提高生存率相关的药物（如溶栓剂和β受体阻滞剂）。
将老年心肌梗死患者的护理从心脏病专家转向初级保健医生的医疗保健策略，降低了资源使用率（并可能降低成本），但也可能导致生存率下降。需要更多信息来阐明初级保健医生和专科医生在重症患者护理中应如何相互协作。
