Laouri M, Kravitz R L, French W J, Yang I, Milliken J C, Hilborne L, Wachsner R, Brook R H
Department of Health Services, University of California-Los Angeles, USA.
J Am Coll Cardiol. 1997 Apr;29(5):891-7. doi: 10.1016/s0735-1097(96)00434-2.
Our main objective was to apply a new method to determine whether coronary revascularization procedures are underused, especially among African-Americans and uninsured patients.
Although overuse of revascularization procedures has been studied, underuse as defined clinically has not been examined before.
The study was conducted at four public and two academically affiliated private hospitals in Los Angeles; 671 patients who underwent coronary angiography between June 1, 1990 and September 30, 1991 and met explicit clinical criteria for coronary revascularization were included. The main outcome measure was the proportion of patients undergoing an indicated procedure within 12 months (ascertained by medical record review and confirmed with a telephone survey). Adjusted relative odds of undergoing an indicated procedure for African-Americans and patients in public hospitals compared with whites and patients in private hospitals were calculated.
Overall, 75% of patients underwent a revascularization procedure. Of 424 patients requiring bypass surgery, 107 angioplasty and 140 either bypass surgery or angioplasty, 59%, 66% and 75% underwent the procedure, respectively. African-Americans were less likely than whites to undergo operation (adjusted odds ratio [OR] 0.49, p < 0.05) and angioplasty (adjusted OR 0.20, p < 0.05). Patients in public hospitals were less likely than those in private hospitals to undergo angioplasty (adjusted OR 0.10, p < 0.005).
Underuse of coronary revascularization procedures is measurable and occurs to a significant degree even among insured patients attending private hospitals. Underuse is especially pronounced among African-Americans and patients attending public hospitals. Future cost-containment efforts must incorporate safeguards against underuse of necessary care.
我们的主要目的是应用一种新方法来确定冠状动脉血运重建手术是否未得到充分利用，尤其是在非裔美国人和未参保患者中。
尽管已经对血运重建手术的过度使用进行了研究，但临床定义的未充分使用此前尚未得到研究。
该研究在洛杉矶的四家公立医院和两家学术附属私立医院进行；纳入了1990年6月1日至1991年9月30日期间接受冠状动脉造影且符合冠状动脉血运重建明确临床标准的671例患者。主要结局指标是在12个月内接受指定手术的患者比例（通过病历审查确定并经电话调查确认）。计算了非裔美国人和公立医院患者与白人和私立医院患者相比接受指定手术的调整相对比值。
总体而言，75%的患者接受了血运重建手术。在424例需要搭桥手术、107例需要血管成形术以及140例需要搭桥手术或血管成形术的患者中，分别有59%、66%和75%接受了该手术。非裔美国人比白人接受手术（调整后的比值比[OR]为0.49，p<0.05）和血管成形术（调整后的OR为0.20，p<0.05）的可能性更小。公立医院的患者比私立医院的患者接受血管成形术的可能性更小（调整后的OR为0.10，p<0.005）。
冠状动脉血运重建手术的未充分使用是可衡量的，甚至在私立医院就诊的参保患者中也有显著程度的发生。未充分使用在非裔美国人和公立医院就诊的患者中尤为明显。未来的成本控制措施必须纳入防止必要治疗未得到充分利用的保障措施。
