Medical Decision Making in the Choice of a Thrombolytic Agent for Acute Myocardial Infarction
Medical Decision Making in the Choice of a Thrombolytic Agent for Acute Myocardial Infarction
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DOI：
10.1177/0272989x9901900409
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发表时间：
1999-10
影响因子：
3.6
通讯作者：
中科院分区：
文献类型：
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作者：
当证据不完整或有争议时，医生如何做出决定，人们知之甚少。虽然溶栓治疗可提高急性心肌梗死（AMI）后的生存率，但对于任何特定药物的优越性存在相互矛盾的证据，特别是如果考虑成本效益。使用贝叶斯分层模型，作者研究了患者、医生和医院的特征，这些特征与1,165例接受溶栓治疗的AMI患者的前瞻性登记研究中选择溶栓药物的决策过程有关。组织纤溶酶原激活剂（t-PA）432例（31.8%）和链激酶（SK）的其余。存在前壁梗死、既往心肌梗死、低血压、心脏病专家决策者、年龄较小以及在症状开始后6小时内接受治疗是接受t-PA的独立预测因素。医生对这些患者特征的重视程度因其执业机构而异。一般来说，他们遵循循证医学，合理地针对高危患者接受更昂贵的t-PA。然而，他们也优先治疗年轻患者，其中似乎只存在一个小的绝对优势。
Little is known about how physicians make decisions when the evidence is incomplete or controversial. While thrombolysis improves survival following acute myocardial infarction (AMI), conflicting evidence exists as to any specific agent's superiority, particularly if cost-effectiveness is considered. Using a Bayesian hierarchical model, the authors examined the patient, physician, and hospital characteristics that are related to the decision-making process concerning the choice of thrombolytic agent in a prospective registry of 1,165 AMI patients receiving thrombolysis. Tissue plasminogen activator (t-PA) was administered to 432 patients (31.8%) and streptokinase (SK) to the remainder. The presence of an anterior infarction, a previous myocardial infarction, low blood pressure, a cardiologist decision maker, younger age, and receiving treatment within six hours after the start of symptoms were independent predictors of receiving t-PA. The levels of importance that physicians accorded to these patient characteristics differed according to their practicing institutions. Generally, they followed evidence-based medicine and reasonably targeted high-risk patients to receive the more expensive t-PA. However, they also preferentially treated younger patients, where only a small absolute advantage appears to exist.