The association between hospital volume and survival after acute myocardial infarction in elderly patients.
The association between hospital volume and survival after acute myocardial infarction in elderly patients.
复制标题
老年患者急性心肌梗死后住院量与生存率的关系。
DOI：
10.1097/00132586-200006000-00012
复制
发表时间：
1999
期刊：
影响因子：
--
通讯作者：
N. Powe
中科院分区：
文献类型：
--
作者：
D. Thiemann;J. Coresh;W. Oetgen;N. Powe
背景
因急性冠状动脉缺血而出现胸痛的患者通常会被救护车送往最近的医院。直接对治疗大量心肌梗塞患者的医院进行现场分诊的潜在好处尚不清楚。
方法
我们对 98,898 名 65 岁或以上的 Medicare 患者进行了一项回顾性队列研究，研究研究中各医院治疗的 Medicare 心肌梗死患者数量（医院容量）与长期生存率之间的关系。我们使用比例风险方法来调整临床、人口统计和卫生系统相关变量，包括侵入性手术的可用性、主治医生的专业以及患者的居住地区（农村、城市或大都市）。
结果
入院人数最少的医院的患者入院后 30 天内死亡的可能性比入院人数最多的医院的患者高出 17%（风险比为 1.17；95% 置信区间为 1.09 至 1.26；P<0.001），这导致每 100 名患者死亡人数增加 2.3 人。收治人数最少的医院的患者一年粗死亡率为 29.8%，而收治人数最多的医院的患者一年粗死亡率为 27.0%。医院容量与死亡风险之间存在连续的反剂量反应关系。在根据年龄、心脏病史、Killip 梗塞分级、是否存在溶栓治疗禁忌症以及症状出现时间定义的亚组分析中，大容量医院的生存率始终优于小容量医院。血管成形术和搭桥手术技术的可用性与总死亡率并不独立相关。
结论
直接入住那些有更多治疗心肌梗塞经验的医院（从病例数量来看）的急性心肌梗死患者比入住低容量医院的患者更有可能存活。
BACKGROUND
Patients with chest pain thought to be due to acute coronary ischemia are typically taken by ambulance to the nearest hospital. The potential benefit of field triage directly to a hospital that treats a large number of patients with myocardial infarction is unknown.
METHODS
We conducted a retrospective cohort study of the relation between the number of Medicare patients with myocardial infarction that each hospital in the study treated (hospital volume) and long-term survival among 98,898 Medicare patients 65 years of age or older. We used proportional-hazards methods to adjust for clinical, demographic, and health-system-related variables, including the availability of invasive procedures, the specialty of the attending physician, and the area of residence of the patient (rural, urban, or metropolitan).
RESULTS
The patients in the quartile admitted to hospitals with the lowest volume were 17 percent more likely to die within 30 days after admission than patients in the quartile admitted to hospitals with the highest volume (hazard ratio, 1.17; 95 percent confidence interval, 1.09 to 1.26; P<0.001), which resulted in 2.3 more deaths per 100 patients. The crude mortality rate at one year was 29.8 percent among the patients admitted to the lowest-volume hospitals, as compared with 27.0 percent among those admitted to the highest-volume hospitals. There was a continuous inverse dose-response relation between hospital volume and the risk of death. In an analysis of subgroups defined according to age, history of cardiac disease, Killip class of infarction, presence or absence of contraindications to thrombolytic therapy, and time from the onset of symptoms, survival at high-volume hospitals was consistently better than at low-volume hospitals. The availability of technology for angioplasty and bypass surgery was not independently associated with overall mortality.
CONCLUSIONS
Patients with acute myocardial infarction who are admitted directly to hospitals that have more experience treating myocardial infarction, as reflected by their case volume, are more likely to survive than are patients admitted to low-volume hospitals.