Temporal changes in the outcomes of acute myocardial infarction in Ontario, 1992-1996

BACKGROUND: There is relatively little information available on recent population-based trends in the outcomes of patients who have had an acute myocardial infarction (AMI). We, therefore, conducted a study of temporal trends in the outcomes of AMI patients in Ontario, Canada, between the 1992 and 1996 fiscal years. METHODS: 114,618 AMI patients were discharged from hospitals in Ontario between Apr. 1, 1992, and Mar. 31, 1997. After specific exclusion criteria were applied the final sample of 89,456 patients was divided into 5 cohorts according to the fiscal year of discharge. As part of the Ontario Myocardial Infarction Database project the linked administrative data pertaining to these patients were used to examine cohort characteristics, cardiac procedures used and mortality rates for each of the 5 cohorts over time. RESULTS: There was a significant increase in the percentage of patients in Ontario receiving coronary angiography, percutaneous transluminal coronary angioplasty and coronary artery bypass grafting surgery (p < 0.001) after an AMI between 1992 and 1996. In addition, the overall 30-day risk-adjusted mortality rate declined from 15.5% in 1992 to 14.0% in 1996 (p = 0.001) and the 1-year risk-adjusted mortality rate declined from 23.7% in 1992 to 22.3% in 1996 (p = 0.017). Virtually all of the improvement occurred within 30 days of admission. The absolute decline in 1-year mortality rates was significant for patients under the age of 65 (2.3%, 95% confidence interval [CI] 1.4% to 3.2%) and for males (1.2%, 95% CI 0.2% to 2.2%); absolute declines were not significant for patients 65 years of age or older (0.7%, 95% CI -0.6% to 2.0%) and for female patients (-0.1%, 95% CI -1.7% to 1.5%). Interestingly, post-infarction coronary angiography and coronary artery bypass grafting rates were consistently lower in the older and the female patients throughout the study period. INTERPRETATION: There was a modest improvement in the short- and long-term survival of patients in Ontario after an AMI between 1992 and 1996. The Ontario experience suggests that recent advances in AMI management have been of more benefit to younger and male AMI patients.     

Sex differences in cardiac catheterization: the role of physician gender.

CONTEXT: Many studies indicate that women are less likely than men to undergo cardiac procedures after an acute myocardial infarction (AMI), raising concerns of sexual bias in clinical care. However, no data exist regarding the relationship between patient sex, physician sex, and use of cardiac procedures. OBJECTIVE: To determine whether sex differences in cardiac catheterization after AMI were greater when patients were treated by male attending physicians compared with female attending physicians. DESIGN, SETTING, AND PATIENTS: Analysis of data from the Cooperative Cardiovascular Project, a retrospective medical record review. A total of 104 >231 Medicare fee-for-service beneficiaries who were hospitalized in US acute care hospitals for an AMI between January 1994 and February 1995. MAIN OUTCOME MEASURE: Use of cardiac catheterization within 60 days of admission, compared between the 4 groups of patient sex-physician sex combinations. RESULTS: Women underwent fewer cardiac catheterizations than men when treated by either male physicians (38.6% vs 50.8%; P =.001) or female physicians (34.8% vs 45.8%; P =.001). Sex differences in procedure use were not greater when a patient and physician were of different sexes (P for interaction =.85). After potential confounders in multivariable analysis were accounted for, women were less likely to undergo cardiac catheterization (risk ratio, 0.90 [95% confidence interval (CI), 0.88-0.92]), regardless of the treating physician's sex. Patients treated by male physicians were more likely to undergo cardiac catheterization (risk ratio, 1.06 [95%CI, 1.02-1.10]) than those treated by female physicians, regardless of patient sex. CONCLUSIONS: Women who have had an AMI undergo a cardiac catheterization less often than men, whether treated by a male or female physician. These results suggest that factors other than sexual bias by male physicians toward women account for sex differences in cardiac procedure use.     

Primary coronary angioplasty vs thrombolysis for the management of acute myocardial infarction in elderly patients.

CONTEXT: Despite evidence from randomized trials that, compared with early thrombolysis, primary percutaneous transluminal coronary angioplasty (PTCA) after acute myocardial infarction (AMI) reduces mortality in middle-aged adults, whether elderly patients with AMI are more likely to benefit from PTCA or early thrombolysis is not known. OBJECTIVE: To determine survival after primary PTCA vs thrombolysis in elderly patients. DESIGN: The Cooperative Cardiovascular Project, a retrospective cohort study using data from medical charts and administrative files. SETTING: Acute care hospitals in the United States. PATIENTS: A total of 20683 Medicare beneficiaries, who arrived within 12 hours of the onset of symptoms, were admitted between January 1994 and February 1996 with a principal discharge diagnosis of AMI, and were eligible for reperfusion therapy. MAIN OUTCOME MEASURES: Thirty-day and 1-year survival. RESULTS: A total of 80356 eligible patients had an AMI at hospital arrival and met the inclusion criteria, of whom 23.2% received thrombolysis and 2.5% underwent primary PTCA within 6 hours of hospital arrival. Patients undergoing primary PTCA had lower 30-day (8.7% vs 11.9%, P=.001) and 1-year mortality (14.4% vs 17.6%, P=.001). After adjusting for baseline cardiac risk factors and admission and hospital characteristics, primary PTCA was associated with improved 30-day (hazard ratio [HR] of death, 0.74; 95% confidence interval [CI], 0.63-0.88) and 1-year (HR, 0.88; 95% CI, 0.73-0.94) survival. The benefits of primary coronary angioplasty persisted when stratified by hospitals' AMI volume and the presence of on-site angiography. In patients classified as ideal for reperfusion therapy, the mortality benefit of primary PTCA was not significant at 1-year follow-up (HR, 0.92; 95% CI, 0.78-1.08). CONCLUSION: In elderly patients who present with AMI, primary PTCA is associated with modestly lower short- and long-term mortality rates. In the subgroup of patients who were classified as ideal for reperfusion therapy, the observed benefit of primary PTCA was no longer significant.     

Relation between operator and hospital volume and outcomes following percutaneous coronary interventions in the era of the coronary stent

Context  Studies have found an association between physician and institution procedure volume for percutaneous coronary interventions (PCIs) and patient outcomes, but whether implementation of coronary stents has allowed low-volume physicians and centers to achieve outcomes similar to their high-volume counterparts is unknown. Objective  To assess the relationship between physician and hospital PCI volumes and patient outcomes following PCIs, given the availability of coronary stents. Design, Setting, and Participants  Analysis of data from Medicare National Claims History files for 167 208 patients aged 65 to 99 years who had PCIs performed by 6534 physicians at 1003 hospitals during 1997. Of these procedures, 57.7% involved coronary stents. Main Outcome Measures  Rates of coronary artery bypass graft (CABG) surgery and 30-day mortality occurring during the index episode of care, stratified by physician and hospital PCI volume. Results  Overall unadjusted rates of CABG during the index hospitalization and 30-day mortality were 1.87% and 3.30%, respectively. After adjustment for case mix, patients treated by low-volume (<30 Medicare procedures) physicians had an increased risk of CABG vs patients treated by high-volume (>60 Medicare procedures) physicians (2.25% vs 1.55%; P<.001), but there was no difference in 30-day mortality rates (3.25% vs 3.39%; P = .27). Patients treated at low-volume (<80 Medicare procedures) centers had an increased risk of 30-day mortality vs patients treated at high-volume (>160 Medicare procedures) centers (4.29% vs 3.15%; P<.001), but there was no difference in the risk of CABG (1.83% vs 1.83%; P = .96). In patients who received coronary stents, the CABG rate was 1.20% vs 2.78% for patients not receiving stents, and the 30-day mortality rate was 2.83% vs 3.94%. Among patients who received stents, those treated at low-volume centers had an increased risk of 30-day mortality vs those treated at high-volume centers, whereas those treated by low-volume physicians had an increased risk of CABG vs those treated by high-volume physicians. Conclusion  In the era of coronary stents, Medicare patients treated by high-volume physicians and at high-volume centers experience better outcomes following PCIs.      

Relationship of hospital teaching status with quality of care and mortality for Medicare patients with acute MI

CONTEXT: Issues of cost and quality are gaining importance in the delivery of medical care, and whether quality of care is better in teaching vs nonteaching hospitals is an essential question in this current national debate. OBJECTIVE: To examine the association of hospital teaching status with quality of care and mortality for fee-for-service Medicare patients with acute myocardial infarction (AMI). DESIGN, SETTING, AND PATIENTS: Analysis of Cooperative Cardiovascular Project data for 114,411 Medicare patients from 4361 hospitals (22,354 patients from 439 major teaching hospitals, 22,493 patients from 455 minor teaching hospitals, and 69,564 patients from 3467 nonteaching hospitals) who had AMI between February 1994 and July 1995. MAIN OUTCOME MEASURES: Administration of reperfusion therapy on admission, aspirin during hospitalization, and beta-blockers and angiotensin-converting enzyme inhibitors at discharge for patients meeting strict inclusion criteria; mortality at 30, 60, and 90 days and 2 years after admission. RESULTS: Among major teaching, minor teaching, and nonteaching hospitals, respectively, administration rates for aspirin were 91.2%, 86.4%, and 81.4% (P<.001); for angiotensin-converting enzyme inhibitors, 63. 7%, 60.0%, and 58.0% (P<.001); for beta-blockers, 48.8%, 40.3%, and 36.4% (P<.001); and for reperfusion therapy, 55.5%, 58.9%, and 55.2% (P =.29). Differences in unadjusted 30-day, 60-day, 90-day, and 2-year mortality among hospitals were significant at P<.001 for all time periods, with a gradient of increasing mortality from major teaching to minor teaching to nonteaching hospitals. Mortality differences were attenuated by adjustment for patient characteristics and were almost eliminated by additional adjustment for receipt of therapy. CONCLUSIONS: In this study of elderly patients with AMI, admission to a teaching hospital was associated with better quality of care based on 3 of 4 quality indicators and lower mortality. JAMA. 2000;284:1256-1262     

Measuring quality of care with explicit process criteria before and after implementation of the DRG-based prospective payment system

We developed explicit process criteria and scales for Medicare patients hospitalized with congestive heart failure, myocardial infarction, pneumonia, cerebrovascular accident, and hip fracture. We applied the process scales to a nationally representative sample of 14,012 patients hospitalized before and after the implementation of the diagnosis related group-based prospective payment system. For the four medical diseases, a better process of care resulted in lower mortality rates 30 days after admission. Patients in the upper quartile of process scores had a 30-day mortality rate 5% lower than that of patients in the lower quartile. The process of care improved after the introduction of the prospective payment system; eg, better nursing care after the introduction of the prospective payment system was associated with an expected decrease in 30-day mortality rates in pneumonia patients of 0.8 percentage points, and better physician cognitive performance was associated with an expected decrease in 30-day mortality rates of 0.4 percentage points. Overall, process improvements across all four medical conditions were associated with a 1 percentage point reduction in 30-day mortality rates after the introduction of the prospective payment system.     

Long-term MI outcomes at hospitals with or without on-site revascularization

CONTEXT: Many studies have found that patients with acute myocardial infarction (AMI) who are admitted to hospitals with on-site revascularization facilities have higher rates of invasive cardiac procedures and better outcomes than patients in hospitals without such facilities. Whether such differences are due to invasive procedure rates alone or to other patient, physician, and hospital characteristics is unknown. OBJECTIVE: To determine whether invasive procedural rate variations alone account for outcome differences in patients with AMI admitted to hospitals with or without on-site revascularization facilities. DESIGN: Retrospective, observational cohort study using linked population-based administrative data from a universal health insurance system. SETTING: One hundred ninety acute care hospitals in Ontario, 9 of which offered invasive procedures. PATIENTS: A total of 25 697 patients hospitalized with AMI between April 1, 1992, and December 31, 1993, of whom 2832 (11%) were in invasive hospitals. MAIN OUTCOME MEASURES: Mortality, recurrent cardiac hospitalizations, and emergency department visits in the 5 years following the index admission, adjusted for patient age, sex, socioeconomic status, illness severity, and index revascularization procedures; attending physician specialty; and hospital volume, teaching status, and geographical proximity to invasive-procedure centers and compared by hospital type. RESULTS: Patients admitted to invasive-procedure hospitals were much more likely to undergo revascularization (11.4% vs 3.2% at other hospitals; P<.001). However, many other clinical and process-related factors differed between the 2 groups. Although mortality rates were similar between the 2 institution types, the nonfatal composite 5-year event rate (ie, recurrent cardiac hospitalization and emergency department visits) was lower for patients initially admitted to invasive-procedure hospitals (71.3% vs 80.4%; unadjusted odds ratio [OR], 0.65; 95% confidence interval [CI], 0.52-0.82; P<.001). This advantage persisted after adjustment for sociodemographic and clinical factors and procedure utilization (adjusted OR, 0.68; 95% CI, 0.53-0.89; P<.001). However, the nonfatal outcome advantages of invasive-procedure hospitals were explained by their teaching status (adjusted OR, 0.98; 95% CI, 0.73-1.30; P =.87). CONCLUSIONS: In this sample of patients admitted with AMI, the differing outcomes of apparently similar patients treated in 2 different practice settings were explained by multiple competing factors. Researchers conducting observational studies should be cautious about attributing patient outcome differences to any single factor.     

急性心肌梗死用瑞替普酶溶栓后早期行补救性PCI的疗效及安全性临床观察

目的:应用第三代溶栓药物瑞替普酶冶疗急性心肌梗死,对未能溶通的病例,及时进行补救性经皮冠脉成形术(PCI),评价其疗效及安全性。方法:自2002年3月～2005年3月,共计30例患者,男性21例,女性9例,年龄41～65岁,其中前壁心肌梗死18例,前壁伴下壁或高侧壁心肌梗死7例,急性下壁心肌梗死5例。发病6h内,用瑞替普酶溶栓治疗,溶栓后2h内,未出现再灌注心律失常、心绞痛未缓解或加重者;心电图抬高的ST段回降<50%。进行冠脉造影,显示闭塞90%以上狭窄病变,同时进行冠脉支架置入术,至术后35d,观察病死率,心力衰竭发生率,血管重建;并且与既往入我科诊断急性心肌梗死经溶栓治疗,未溶通的30例病例做比较。结果:30例应用瑞替普酶溶栓后补救性PCI的患者与对照组比较,成功率96.7%,35d内病死率(0;20,P<0.00l);心力衰竭发生率(3.4%;65%),血管重建率(0;33%),大出血发生率(3.3%;0)。结论:用瑞替普酶溶栓后对未溶通的患者行补救性PCI,初步认为是有效的、安全的。     

Early statin treatment following acute myocardial infarction and 1-year survival

CONTEXT: Randomized trials have established statin treatment as secondary prevention in coronary artery disease, but it is unclear whether early treatment with statins following acute myocardial infarction (AMI) influences survival. OBJECTIVE: To evaluate the association between statin treatment initiated before or at the time of hospital discharge and 1-year mortality after AMI. DESIGN AND SETTING: Prospective cohort study using data from the Swedish Register of Cardiac Intensive Care on patients admitted to the coronary care units of 58 Swedish hospitals in 1995-1998. One-year mortality data were obtained from the Swedish National Cause of Death Register. PATIENTS: Patients with first registry-recorded AMI who were younger than 80 years and who were discharged alive from the hospital, including 5528 who received statins at or before discharge and 14 071 who did not. MAIN OUTCOME MEASURE: Relative risk of 1-year mortality according to statin treatment. RESULTS: At 1 year, unadjusted mortality was 9.3% (1307 deaths) in the no-statin group and 4.0% (219 deaths) in the statin treatment group. In regression analysis adjusting for confounding factors and propensity score for statin use, early statin treatment was associated with a reduction in 1-year mortality (relative risk, 0.75; 95% confidence interval, 0.63-0.89; P =.001) in hospital survivors of AMI. This reduction in mortality was similar among all subgroups based on age, sex, baseline characteristics, previous disease manifestations, and medications. CONCLUSIONS: Early initiation of statin treatment in patients with AMI is associated with reduced 1-year mortality. These results emphasize the importance of implementing the results of randomized statin trials in unselected AMI patients.     

Prior alcohol consumption and mortality following acute myocardial infarction

CONTEXT: Studies have found that individuals who consume 1 alcoholic drink every 1 to 2 days have a lower risk of a first acute myocardial infarction (AMI) than abstainers or heavy drinkers, but the effect of prior drinking on mortality after AMI is uncertain. OBJECTIVE: To determine the effect of prior alcohol consumption on long-term mortality among early survivors of AMI. DESIGN AND SETTING: Prospective inception cohort study conducted at 45 US community and tertiary care hospitals between August 1989 and September 1994, with a median follow-up of 3.8 years. PATIENTS: A total of 1913 adults hospitalized with AMI between 1989 and 1994. MAIN OUTCOME MEASURE: All-cause mortality, compared by self-reported average weekly consumption of beer, wine, and liquor during the year prior to AMI. RESULTS: Of the 1913 patients, 896 (47%) abstained from alcohol, 696 (36%) consumed less than 7 alcoholic drinks/wk, and 321 (17%) consumed 7 or more alcoholic drinks/wk. Compared with abstainers, patients who consumed less than 7 drinks/wk had a lower all-cause mortality rate (3.4 vs 6.3 deaths per 100 person-years; hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.43-0.71) as did those who consumed 7 or more drinks/wk (2.4 vs 6.3 deaths per 100 person-years; HR, 0.38; 95% CI, 0.25-0.55; P<.001 for trend). After adjusting for propensity to drink and other potential confounders, increasing alcohol consumption remained predictive of lower mortality for less than 7 drinks/wk, with an adjusted HR of 0.79 (95% CI, 0.60-1.03), and for 7 or more drinks/wk, with an adjusted HR of 0.68 (95% CI, 0.45-1.05; P =.01 for trend). The association was similar for total and cardiovascular mortality, among both men and women, and among different types of alcoholic beverages. CONCLUSION: Self-reported moderate alcohol consumption in the year prior to AMI is associated with reduced mortality following infarction.     

Discrepancies between patient and physician estimates for the success of stem cell transplantation

CONTEXT: Stem cell transplantation is associated with considerable morbidity and mortality. The extent to which patients and their physicians correctly estimate these risks is unknown. OBJECTIVE: To measure the expectations of patients and physicians prior to stem cell transplantation and correlate them with actual outcomes after transplantation. DESIGN: Prospective cohort study with baseline questionnaire administered July 1996 through November 1999 and follow-up to May 2000. SETTING: Tertiary care transplant center in the United States. PARTICIPANTS: Of 458 surveys mailed, evaluable returned surveys were included for 313 autologous and allogeneic stem cell transplantation patients and their physicians. MAIN OUTCOME MEASURES: Patient and physician expectations prior to transplantation (measured on 6-point Likert scales) of treatment-related mortality, cure with transplantation, and cure without transplantation; actual treatment-related mortality and disease-free survival among patients with at least 1 year of follow-up after transplantation (n = 263). RESULTS: Both patients and physicians were fairly accurate in estimating treatment-related mortality when actual mortality was less than 30%. However, in situations in which mortality was higher than 30%, such as with allogeneic transplantation for intermediate or advanced disease, physician expectations were lower, while patients remained optimistic. Similarly, physicians provided lower estimates of disease-free survival in cases of intermediate or advanced disease while patient expectations remained high and constant regardless of disease stage. CONCLUSIONS: Patients and their physicians have the most concordant and accurate expectations when the outcome of stem cell transplantation is likely to be favorable. However, patients with more advanced disease fail to recognize the higher risks associated with their situations.     

The effects of quality improvement interventions on inhospital mortality after acute myocardial infarction.

OBJECTIVE: To evaluate the effects of quality improvement interventions on inhospital mortality after admission for acute myocardial infarction (AMI). DESIGN: Before-and-after study (with concurrent controls) based on hospital discharge data from a routinely maintained, administrative database. SETTING: All Queensland public hospitals, July 1991 - June 1999. STUDY POPULATION: Patients with AMI admitted through the emergency department. Intervention: Development and promulgation of clinical practice guidelines at one hospital, combined with regular audit and feedback, commencing November 1995. MAIN OUTCOME MEASURES: Inhospital mortality (adjusted for age, sex and comorbidities) for four-year periods before (1991-92 to 1994-95) and after (1995-96 to 1998-99) initiation of quality improvement interventions. RESULTS: Before the intervention, the adjusted odds ratio (OR) for inhospital death at the intervention hospital was about the same as at other public hospitals (adjusted OR, 0.99; 95% CI, 0.80-1.24), but was more than 40% lower after the intervention (adjusted OR, 0.59; 95% Cl, 0.45-0.78). After the intervention, the risk of death at the intervention hospital was lower compared with hospitals with cardiologists as admitting practitioners (adjusted OR, 0.63; 95% CI, 0.48-0.83), with onsite revascularisation facilities (adjusted OR, 0.66; 95% CI, 0.49-0.88), and with large numbers (> or = 250 per year) of annual admissions of patients with AMI (adjusted OR, 0.72; 95% CI, 0.54-0.97). CONCLUSIONS: Quality improvement interventions lower the risk of inhospital death in patients with AMI. Implementation of such interventions in all hospitals may confer a risk of death lower than that achieved by admitting all patients under the care of cardiologists, or to hospitals with revascularisation facilities or a high volume of admissions of patients with AMI.     

急性心肌梗死再灌注治疗的临床研究

目的：比较不同再灌注治疗方案治疗急性心肌梗死（ＡＭＩ）的疗效和预后。方法：１１９例采用常规药物治疗,５７例行静脉溶栓、１４例行冠状动态内容栓（ＰＴＣＲ）、１２例行急诊经皮冠状动脉成形术（ＰＴＣＡ）。结果：静脉溶栓治疗冠状动脉再通率为５２．６％,其中,ＡＭＩ发生〈６ｈ者再通率为６７．６％,〉６ｈ者再通率仅为２０％。ＰＴＣＲ再通率为５０％。急诊ＰＴＣＡ手术成功率为９１．７％,２例植入冠状动脉支架成功。     

天普洛欣静脉溶栓治疗急性心肌梗死92例临床分析

目的：分析天普洛欣静脉溶栓治疗对急性心肌梗死（AMI）患者的疗效与安全性。方法：选择符合静脉溶栓标准的AMI192例患者给予静滴天普洛欣（尿激酶）150万u,并辅以阿斯匹林、肝素及常规治疗,观察冠脉再通及心脏事件发生率、5周死亡率及出血倾向。结果：①冠脉再通62例,其再通率67．4％;②发病至开始溶栓时间＜6h患者,冠脉再通率达81％,＞6h者仅50％（P＜0．005）;③冠脉再通患者的心脏事件发生率为30．65％,5周死亡率为4．84％,而未通患者分别为53．33％和20％（P＜0．025～0．05）;④出现出血倾向10例。结论：天普洛欣静脉溶栓治疗AMI有效且相对安全。     

Coronary artery bypass grafting in Canada: national and provincial mortality trends, 1992-1995

BACKGROUND: Despite a body of research on outcomes of coronary artery bypass grafting (CABG) in Canada, little is known about Canada-wide outcome trends and interregional differences in outcome. The objectives of this study were to examine Canadian trends in rates of in-hospital death after CABG and to compare provincial risk-adjusted death rates. METHODS: Hospital discharge data were obtained from the Canadian Institute for Health Information and were used to identify complete cohorts of patients who underwent CABG in 8 provinces in fiscal years 1992/93 through 1995/96. Data from Quebec hospitals were not available. A logistic regression model was used to calculate risk-adjusted death rates by year, province, and province and year. RESULTS: A total of 50,357 CABG cases were studied, with an overall death rate of 3.6%. A national trend of decreasing mortality was found, with a risk-adjusted death rate of 3.8% in 1992/93 versus 3.2% in 1995/96 (relative decrease of 17%) (p < 0.001 for difference across years). Some provinces (e.g., Alberta, Manitoba and Ontario) achieved overall declines in death rates over the study period, whereas others (e.g., British Columbia and Saskatchewan) did not. The average severity of illness of patients who underwent CABG differed considerably across provinces. Despite risk adjustment for these differences, provincial death rates varied significantly (p < 0.001). INTERPRETATION: Rates of death after CABG in Canada decreased significantly in a relatively short period. Despite this encouraging finding, there were interprovincial differences in severity of illness and risk-adjusted death rates. This finding raises the possibility of unequal access to CABG and variable quality of care for patients undergoing the surgery across Canadian provinces.     

医师诊治量和专业陛对急性心肌梗死住院死亡率的影响

目的通过对北京市某综合性三级甲等医院1998～2002年急性心肌梗死诊疗情况的分析,评估该院医师诊治量和专业性对急性心肌梗死住院死亡率的影响.方法选择1998～2002年出院第一诊断为急性心肌梗死的入选病人,对其病案首页资料进行分析,依医师诊治量多少和专业性不同分别比较其对急性心肌梗死住院死亡率的影响.结果五年入选病人2009例,其住院死亡率为5.5%.高医师诊治量组病人住院死亡率4.9%(79/1606)比低医师诊治量组病人住院死亡率7.7%(31/403)低(P＜0.05).心脏科医师组与非心脏科医师组相比具有较低的住院死亡率,在年龄≤65岁组分别为1.8%(18/999)、7.0%(6/86)(P＜0.01),在年龄＞65岁组分别为8.1%(66/811)、17.7%(20/113)(P＜0.01).结论经高诊治量和心脏科专业医师处理的急性心肌梗死病人具有较高的生存概率.     

Evaluation of a consumer-oriented internet health care report card: the risk of quality ratings based on mortality data

Context  Health care "report cards" have attracted significant consumer interest, particularly publicly available Internet health care quality rating systems. However, the ability of these ratings to discriminate between hospitals is not known. Objective  To determine whether hospital ratings for acute myocardial infarction (AMI) mortality from a prominent Internet hospital rating system accurately discriminate between hospitals' performance based on process of care and outcomes. Design, Setting, and Patients  Data from the Cooperative Cardiovascular Project, a retrospective systematic medical record review of 141 914 Medicare fee-for-service beneficiaries 65 years or older hospitalized with AMI at 3363 US acute care hospitals during a 4- to 8-month period between January 1994 and February 1996 were compared with ratings obtained from HealthGrades.com (1-star: worse outcomes than predicted, 5-star: better outcomes than predicted) based on 1994-1997 Medicare data. Main Outcome Measures  Quality indicators of AMI care, including use of acute reperfusion therapy, aspirin, -blockers, angiotensin-converting enzyme inhibitors; 30-day mortality. Results  Patients treated at higher-rated hospitals were significantly more likely to receive aspirin (admission: 75.4% 5-star vs 66.4% 1-star, P for trend = .001; discharge: 79.7% 5-star vs 68.0% 1-star, P = .001) and -blockers (admission: 54.8% 5-star vs 35.7% 1-star, P = .001; discharge: 63.3% 5-star vs 52.1% 1-star, P = .001), but not angiotensin-converting enzyme inhibitors (59.6% 5-star vs 57.4% 1-star, P = .40). Acute reperfusion therapy rates were highest for patients treated at 2-star hospitals (60.6%) and lowest for 5-star hospitals (53.6% 5-star, P = .008). Risk-standardized 30-day mortality rates were lower for patients treated at higher-rated than lower-rated hospitals (21.9% 1-star vs 15.9% 5-star, P = .001). However, there was marked heterogeneity within rating groups and substantial overlap of individual hospitals across rating strata for mortality and process of care; only 3.1% of comparisons between 1-star and 5-star hospitals had statistically lower risk-standardized 30-day mortality rates in 5-star hospitals. Similar findings were observed in comparisons of 30-day mortality rates between individual hospitals in all other rating groups and when comparisons were restricted to hospitals with a minimum of 30 cases during the study period. Conclusion  Hospital ratings published by a prominent Internet health care quality rating system identified groups of hospitals that, in the aggregate, differed in their quality of care and outcomes. However, the ratings poorly discriminated between any 2 individual hospitals' process of care or mortality rates during the study period. Limitations in discrimination may undermine the value of health care quality ratings for patients or payers and may lead to misperceptions of hospitals' performance.      

血浆晶体渗透压对急性心肌梗死患者预后影响的研究

目的评估血浆晶体渗透压对急性心肌梗死（AMI）患者临床及预后的影响。方法将102例AMI患者按入院1 h内的血浆晶体渗透压水平分3组,正常血浆晶体渗透压组为N组72例,低血浆晶体渗透压组为L组21例,高血浆晶体渗透压组为H组9例,按照急性心肌梗死诊断和治疗指南处理,观察3组患者发生心力衰竭、心源性休克、心室颤动、Ⅲ度AVB、住院病死率和30d病死率的差异。结果年龄较大,有糖尿病、心肌梗死、脑卒中和心力衰竭病史者更容易出现血浆晶体渗透压异常（P〈0.05）;血浆晶体渗透压异常组更容易并发心力衰竭、心源性休克、心室颤动和Ⅲ°AVB等严重并发症（P〈0.05）;静脉溶栓冠脉再通率也显著降低（P〈0.05）;住院病死率和30d病死率亦明显增加（P〈0.05）。结论 AMI患者早期血浆晶体渗透压异常,其住院病死率和30d病死率明显增加,提示血浆晶体渗透压异常可能是影响AMI患者预后的独立危险因素。     

ICH评分量表对估计高血压性脑出血30天死亡率的研究

目的 判断脑出血评分量表能否准确估计我国高血压性脑出血患者30天的死亡率.方法 回顾性分析2013年1月～2014年1月我院神经外科304例高血压脑出血住院患者的临床资料.收集患者的年龄、性别、血肿量大小、血肿位置、脑室是否出血、GCS、是否手术以及发病后30天的死亡率情况.结果 ICH评分为0、1、2、3、4、5的高血压性脑出血患者30天的死亡率分别为0（0.0％）、8.9％、23.5％、52％、72％和100％.ICH评分与30天死亡率呈正相关（P＜0.05）.对于幕上血肿≥30ml、幕下血肿≥10ml的高血压性脑出血患者,手术治疗可以明显降低30天的死亡率（P＜0.05）.结论 ICH可以准确估计高血压性脑出血患者30天的死亡率,且简单易行,应在我国推广应用.对于幕上血肿≥30ml、幕下血肿≥10ml的高血压性脑出血患者,应尽早行手术治疗.