Regional variation in cardiac catheterization appropriateness and baseline risk after acute myocardial infarction
Regional variation in cardiac catheterization appropriateness and baseline risk after acute myocardial infarction
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DOI：
10.1016/j.jacc.2007.10.039
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发表时间：
2008-02-19
影响因子：
24
通讯作者：
Krumholz, Harlan M.
中科院分区：
文献类型：
--
作者：
Ko, Dennis T.;Wang, Yongfei;Krumholz, Harlan M.
目的我们评估急性心肌梗死（AMI）后心脏介入治疗的适宜性和基线风险是否因区域侵入性治疗强度而异，以及AMI死亡率是否因侵入性治疗强度区域而异。1998年至2001年间因AMI住院的639名医疗保险按服务收费受益人。侵入性手术强度是根据医疗保险登记者的总体心导管插入率确定的。根据美国心脏病学会/美国心脏协会分类确定心导管插入术的适当性，并使用GRACE（急性冠状动脉事件全球登记）风险评分估计基线风险。研究的主要结果是60天内使用心导管和入院后3年的死亡率。结果I类患者侵袭强度较高的区域更可能进行心导管（适用）（RR 1.38，95%置信区间[CI] 1.27 - 1.48），II类患者（不确定）（RR 1.42，95% CI 1.31至1.53）和III类患者（不适当）（RR 1.29，95% 0.97至1.67）与低强度区域相比，调整患者和医生特征后。GRACE风险十分位数每增加一次，总体心导管插入术使用率降低5.2%，并且在所有地区观察到类似的关系。危险标准化死亡率的AMI患者在3年之间没有实质性差异regions.Conclusions虽然高风险的患者和那些更合适的适应症可能有最大的好处，从侵入性的战略后，AMI，我们发现，高侵入性地区不区分程序选择的基础上，患者的适当性或其基线风险。
Objectives We evaluated whether appropriateness and baseline risk of cardiac catheterization varied according to regional intensity of invasive therapy after acute myocardial infarction (AMI), and whether AMI mortality varied according to invasive intensity regions.Background Marked regional variations exist in cardiac invasive procedure use after AMI within the U.S.Methods We performed an analysis of 44,639 Medicare fee-for-service beneficiaries hospitalized with AMI between 1998 and 2001. Invasive procedure intensity was determined based on overall cardiac catheterization rates for Medicare enrollees. Cardiac catheterization appropriateness was determined by the American College of Cardiology/American Heart Association classification and baseline risk was estimated using the GRACE (Global Registry of Acute Coronary Events) risk score. The primary outcomes of the study were cardiac catheterization use within 60 days and 3-year mortality after hospital admission.Results Higher invasive intensity regions were more likely to perform cardiac catheterizations on class I patients (appropriate) (RR 1.38, 95% confidence interval [CI] 1.27 to 1.48), class II patients (equivocal) (RR 1.42, 95% CI 1.31 to 1.53), and class III patients (inappropriate) (RR 1.29, 95% 0.97 to 1.67) compared with low-intensity regions after adjusting for patient and physician characteristics. The overall cardiac catheterization use was 5.2% lower for each increase in GRACE risk decile, and this relationship was observed similarly in all regions. Risk-standardized mortality rates of AMI patients at 3 years were not substantially different between regions.Conclusions Although higher-risk patients and those with more appropriate indications may have the most to benefit from an invasive strategy after AMI, we found that higher-invasive regions do not differentiate procedure selection based on the patients' appropriateness or their baseline risks.