Association of Physician Certification and Outcomes Among Patients Receiving an Implantable Cardioverter-Defibrillator
Association of Physician Certification and Outcomes Among Patients Receiving an Implantable Cardioverter-Defibrillator
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DOI：
10.1001/jama.2009.547
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发表时间：
2009-04-22
影响因子：
120.7
通讯作者：
Krumholz, Harlan M.
中科院分区：
文献类型：
--
作者：
Curtis, Jeptha P.;Luebbert, Jeffrey J.;Krumholz, Harlan M.
允许非电生理学家进行植入式心律转复除颤器（ICD）手术是有争议的。然而，目前尚不清楚ICD植入的结果是否因医生专业而异。目的探讨ICD植入术医师资质与植入术效果的关系。设计、环境和患者回顾性队列研究使用2006年1月至2007年6月间提交ICD登记处的病例。患者根据植入医师的认证状态被分组为相互排斥的类别：电生理学家、非电生理学家心脏病专家、胸外科医生和其他专家。建立了层次逻辑回归模型来确定医生认证与结果的独立关联。住院手术并发症发生率和符合除颤器心脏再同步化治疗（CRT-D）标准的患者接受除颤器的比例。结果纳入分析的11293例ICD植入中，78 857例（70.9%）由电生理医师完成，24 399例（21.9%）由非电生理医师心内科医师完成，1862例（1.7%）由胸外科医师完成，6175例（5.5%）由其他专科医师完成。与由电生理医师植入ICD的患者相比，由非电生理医师心脏科医师或胸外科医师植入ICD的患者在未调整的两种情况下的并发症风险均增加（电生理医师为3.5%[2743/78 857]，非电生理医师心脏科医师为4.0%[970/24 399]，胸外科医师为5.8%[101 /1862]，非电生理医师心脏科医师为5.8%[788 /1862]）。P < 0.001)和校正分析（非电生理学心脏病专家的相对危险度[RR]为1.11[95%可信区间{CI}， 1.01-1.21]；胸外科医生的相对危险度[RR]为1.44 [95% CI, 1.15-1.79]）。在35 841例符合ct - d标准的患者中，由非电生理医生植入ICD的患者接受ct - d装置的可能性明显低于由电生理医生植入ICD的患者（电生理医生为83.1%[21 301 /25 635]，非电生理心脏病医生为75.8%[5950/7849]，胸外科医生为57.8%[269/465]，其他专科医生为74.8%[1416/1892]，其他专科医生为74.8%[1416/1892]）。P < 0.001)和校正分析（非电生理学心脏病专家的RR为0.93 [95% CI, 0.91-0.95]；胸外科医生的RR为0.81 [95% CI, 0.74-0.88]；其他专家的RR为0.97 [95% CI, 0.94-0.99]）。结论：非电生理学家植入了29%的icd。总的来说，与由电生理学家植入ICD的患者相比，由非电生理学家植入ICD的患者出现手术并发症的风险更高，接受ct - d装置的可能性更低。
Context Allowing nonelectrophysiologists to perform implantable cardioverter-defibrillator (ICD) procedures is controversial. However, it is not known whether outcomes of ICD implantation vary by physician specialty.Objective To determine the association of implanting physician certification with outcomes following ICD implantation.Design, Setting, and Patients Retrospective cohort study using cases submitted to the ICD Registry performed between January 2006 and June 2007. Patients were grouped by the certification status of the implanting physician into mutually exclusive categories: electrophysiologists, nonelectrophysiologist cardiologists, thoracic surgeons, and other specialists. Hierarchical logistic regression models were developed to determine the independent association of physician certification with outcomes.Main Outcome Measures In-hospital procedural complication rates and the proportion of patients meeting criteria for a defibrillator with cardiac resynchronization therapy (CRT-D) who received that device.Results Of 111 293 ICD implantations included in the analysis, 78 857 (70.9%) were performed by electrophysiologists, 24 399 (21.9%) by nonelectrophysiologist cardiologists, 1862 (1.7%) by thoracic surgeons, and 6175 (5.5%) by other specialists. Compared with patients whose ICD was implanted by electrophysiologists, patients whose ICD was implanted by either nonelectrophysiologist cardiologists or thoracic surgeons were at increased risk of complications in both unadjusted (electrophysiologists, 3.5% [2743/78 857]; nonelectrophysiologist cardiologists, 4.0% [970/24 399]; thoracic surgeons, 5.8% [108/1862]; P < .001) and adjusted analyses (relative risk [RR] for nonelectrophysiologist cardiologists, 1.11 [95% confidence interval {CI}, 1.01-1.21]; RR for thoracic surgeons, 1.44 [ 95% CI, 1.15-1.79]). Among 35 841 patients who met criteria for CRT-D, those whose ICD was implanted by physicians other than electrophysiologists were significantly less likely to receive a CRT-D device compared with patients whose ICD was implanted by an electrophysiologist in both unadjusted (electrophysiologists, 83.1% [21 303/25 635]; nonelectrophysiologist cardiologists, 75.8% [5950/7849]; thoracic surgeons, 57.8% [269/465]; other specialists, 74.8% [1416/1892]; P < .001) and adjusted analyses ( RR for nonelectrophysiologist cardiologists, 0.93 [95% CI, 0.91-0.95]; RR for thoracic surgeons, 0.81 [95% CI, 0.74-0.88]; RR for other specialists, 0.97 [95% CI, 0.94-0.99]).Conclusions In this registry, nonelectrophysiologists implanted 29% of ICDs. Overall, implantations by a nonelectrophysiologist were associated with a higher risk of procedural complications and lower likelihood of receiving a CRT-D device when indicated compared with patients whose ICD was implanted by an electrophysiologist.