Hospital and emergency department factors associated with variations in missed diagnosis and costs for patients age 65 years and older with acute myocardial infarction who present to emergency departments.
Hospital and emergency department factors associated with variations in missed diagnosis and costs for patients age 65 years and older with acute myocardial infarction who present to emergency departments.
复制标题
与 65 岁及以上急性心肌梗死患者到急诊科就诊的漏诊和费用变化相关的医院和急诊科因素。
DOI：
10.1111/acem.12486
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发表时间：
2014
期刊：
影响因子：
--
通讯作者：
Cutler,David
中科院分区：
文献类型：
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作者：
Wilson,Michael;Welch,Jonathan;Schuur,Jeremiah;O'Laughlin,Kelli;Cutler,David
ObjectivesThe目的是测量老年急性心肌梗死（AMI）患者急诊科（ED）的漏诊和护理费用的变化，并确定与此变化相关的医院和艾德特征。作者确定了一组年龄在65岁及以上的AMI患者，他们到艾德接受初始治疗。主要结局是AMI的漏诊，即，在艾德出院后7天内因提示心脏缺血的状况而入院治疗AMI。费用定义为医疗保险医院支付的所有服务相关的，并立即产生的艾德评价。艾德和医院的特点，质量和成本的影响进行了估计，使用多层次模型与医院随机effects.ResultsThere有371,638 AMI患者年龄65岁及以上的研究，其中4,707人出院回家，从他们最初的艾德访问，随后入院。未校正的医院级漏诊百分比中位数为0.52%（四分位距[IQR] = 0 - 3.45%）。保护不良结局的艾德特征包括较高的艾德胸痛急性程度（校正比值比[aOR] = 0.23，99%置信区间[CI] = 0.19至0.27）和美国急诊医学委员会（ABEM）认证（aOR = 0.60，99% CI = 0.50至0.73）。保护性医院特征包括较大的医院规模（aOR = 0.46，99%CI = 0.37至0.57）和学术地位（aOR = 0.74，99%CI = 0.58至0.94）。所有这些特点都与较高的costs.ConclusionsThe比例错过了AMI诊断和护理费用为65岁及以上的患者提出急诊室与AMI各医院不同。拥有更多委员会认证的急诊医生（EP）和更高平均敏锐度的医院与显着更高的质量相关。所有与更好的艾德结局相关的医院特征都与更高的成本相关。
ObjectivesThe objective was to measure the variation in missed diagnosis and costs of care for older acute myocardial infarction (AMI) patients presenting to emergency departments (EDs) and to identify the hospital and ED characteristics associated with this variation.MethodsUsing 2004–2005 Medicare inpatient and outpatient records, the authors identified a cohort of AMI patients age 65 years and older who presented to the ED for initial care. The primary outcome was missed diagnosis of AMI, i.e., AMI hospital admission within 7 days of an ED discharge for a condition suggestive of cardiac ischemia. Costs were defined as Medicare hospital payments for all services associated with and immediately resulting from the ED evaluation. The effect of ED and hospital characteristics on quality and costs were estimated using multilevel models with hospital random effects.ResultsThere were 371,638 AMI patients age 65 and older included in the study, of whom 4,707 were discharged home from their initial ED visits and subsequently admitted to the hospital. The median unadjusted hospital‐level missed diagnosis percentage was 0.52% (interquartile range [IQR] = 0 to 3.45%). ED characteristics protective of adverse outcomes include higher ED chest pain acuity (adjusted odds ratio [aOR] = 0.23, 99% confidence interval [CI] = 0.19 to 0.27) and American Board of Emergency Medicine (ABEM) certification (aOR = 0.60, 99% CI = 0.50 to 0.73). Protective hospital characteristics include larger hospital size (aOR = 0.46, 99% CI = 0.37 to 0.57) and academic status (aOR = 0.74, 99% CI = 0.58 to 0.94). All of these characteristics were associated with higher costs as well.ConclusionsThe proportion of missed AMI diagnoses and cost of care for patients age 65 years and older presenting to EDs with AMI varies across hospitals. Hospitals with more board‐certified emergency physicians (EPs) and higher average acuity are associated with significantly higher quality. All hospital characteristics associated with better ED outcomes are associated with higher costs.