Race and timeliness of transfer for revascularization in patients with acute myocardial infarction.
Race and timeliness of transfer for revascularization in patients with acute myocardial infarction.
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DOI：
10.1097/mlr.0b013e31821d98b2
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发表时间：
2011-07
期刊：
影响因子：
3
通讯作者：
Iwashyna TJ
中科院分区：
文献类型：
--
作者：
Cooke CR;Nallamothu B;Kahn JM;Birkmeyer JD;Iwashyna TJ
急性心肌梗死（AMI）患者入院时没有冠状动脉血运重建术，经常被转移到有冠状动脉血运重建术的医院。我们试图确定医院转院的及时性和目的地医院的质量在黑人和白人患者之间是否存在差异。我们评估了2006年所有在非血运重建术医院接受急性心肌梗死的白人和黑人医疗保险受益人，并将其转至血运重建术医院。我们比较了黑人和白人患者在转院前的住院时间和转院目的地的30天AMI风险标准化死亡率（RSMR）。我们使用层次回归来调整患者特征，并检查种族对30天死亡率和转院前住院时间的院内和跨院影响。共有25,947例（42%）白人和2,345例（37%）黑人AMI患者从857家城市非血运重建医院和774家农村非血运重建医院转至928家血运重建医院。白人患者转院前的中位（IQR）住院时间为1天（1-3），黑人患者为2天（1-4）（p<0.001）。在调整后的模型中，黑人患者往往比白人患者转移得慢，这一发现是由于医院内外的影响。例如，在给定的城市医院，黑人患者比白人患者多转院0.24天（95% CI 0.03-0.44）。此外，黑人AMI患者比例每增加20%，所有患者在城市医院转院前的住院时间增加0.37天（95% CI 0.28-0.47）。这些结果在农村医院减弱。黑人和白人患者最终被送往的血运重建医院的RSMR没有差异，黑人患者在AMI后转到血运重建医院的速度比白人患者慢，这是由于医院内转院不及时以及入院时转院延误更大；然而，两组送往的血运重建术医院的30天死亡率相似。基于种族的转移延迟可能导致AMI结果的已知种族差异。
Patients with acute myocardial infarction (AMI) who are admitted to hospitals without coronary revascularization are frequently transferred to hospitals with this capability. We sought to determine if the timeliness of hospital transfer and quality of destination hospitals differed between black and white patients. We evaluated all white and black Medicare beneficiaries admitted with AMI at non-revascularization hospitals in 2006 who were transferred to a revascularization hospital. We compared hospital length of stay prior to transfer and the transfer destination's 30-day risk-standardized mortality rate (RSMR) for AMI between black and white patients. We used hierarchical regression to adjust for patient characteristics and examine within- and across-hospital effects of race on 30-day mortality and length of stay prior to transfer. A total of 25,947 (42%) white and 2,345 (37%) black patients with AMI were transferred from 857 urban and 774 rural non-revascularization hospitals to 928 revascularization hospitals. Median (IQR) length of stay prior to transfer was 1 day (1-3) for white patients and 2 days (1-4) for black patients (p<0.001). In adjusted models, black patients tended to be transferred more slowly than white patients, a finding due to both across-hospital and within-hospital effects. For example, within an given urban hospital black patients were transferred an additional 0.24 days (95% CI 0.03-0.44) later than white patients. Additionally, the lengths of stay prior to transfer for all patients at urban hospitals increased by 0.37 days (95% CI 0.28-0.47) for every 20% increase in the proportion of AMI patients who were black. These results were attenuated in rural hospitals. The RSMR of the revascularization hospital to which patients were ultimately sent did not differ between black and white patients Black patients are transferred more slowly to revascularization hospitals after AMI than white patients, resulting from both less timely transfers within hospitals as well as admission to hospitals with greater delays in transfer; however, 30-day mortality of the revascularization hospital to which both groups were sent to appeared similar. Race-based delays in transfer may contribute to known racial disparities in outcomes of AMI.