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1.
Sex differences in evaluation and outcome of unstable angina   总被引:8,自引:2,他引:6  
CONTEXT: The existence of sex bias in the delivery of cardiac care is controversial, and little is known about the association between sex and delivery of care and outcomes at an early point in the diagnostic sequence, such as when patients present for the evaluation of chest pain. OBJECTIVE: To test the hypothesis that female sex is negatively associated with care delivered to and outcomes of persons diagnosed as having unstable angina. DESIGN: Inception population-based cohort study with an average of 6 years of follow-up. SETTING: Emergency departments (EDs) in Olmsted County, Minnesota. PATIENTS: A total of 2271 Olmsted County residents (1306 men and 965 women) who presented to the ED for the first time with symptoms meeting criteria for unstable angina between 1985 and 1992. MAIN OUTCOME MEASURES: Use of cardiac procedures within 90 days of ED visit, overall mortality, and cardiac events (cardiac death, nonfatal myocardial infarction, nonfatal cardiac arrest, and congestive heart failure), compared by sex and Agency for Health Care Policy and Research cardiovascular risk category (low, intermediate, or high). RESULTS: Women were older (P<.001), more likely to have a history of hypertension (P = .001), and less likely to present with typical angina (P = .004) than men. Men were more likely than women to undergo noninvasive cardiac tests (relative risk [RR], 1.27; 95% confidence interval [CI], 1.14-1.40) as well as invasive cardiac procedures (RR, 1.72; 95% CI, 1.51-1.97). After adjustment, male sex was associated with a 24% increase in the use of cardiac procedures. Survival of both men and women in the high and intermediate risk categories was significantly lower than expected per the general population (P<.001). Women had a worse outcome than men, but after multivariate adjustment, male sex was associated with a trend toward an increase in the risk of death (RR, 1.23; 95% CI, 0.99-1.54) and significantly associated with increased risk of cardiac events (RR, 1.21; 95% CI, 1.03-1.42). CONCLUSIONS: Our population-based data indicate that after an ED visit for symptoms of unstable angina, the use of cardiac procedures was lower in women, but after taking into account baseline characteristics, men experienced worse outcomes.  相似文献   

2.
Alter DA  Naylor CD  Austin PC  Tu JV 《JAMA》2001,285(16):2101-2108
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.  相似文献   

3.
J V Tu  P C Austin  B T Chan 《JAMA》2001,285(24):3116-3122
CONTEXT: Acute myocardial infarction (AMI) is a common condition that is treated by physicians with varying levels of clinical experience, but whether the level of experience affects outcome remains uncertain. OBJECTIVE: To evaluate the relationship between the average annual volume of cases treated by admitting physicians and mortality after AMI. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study using linked administrative databases containing patient admission information for 98 194 patients treated by 5374 physicians between April 1, 1992, and March 31, 1998, in Ontario, Canada. MAIN OUTCOME MEASURES: Mortality risk rates for 30 days and 1 year post-AMI, adjusted by physician volume and patient, physician, and hospital characteristics. RESULTS: The 30-day mortality rate was 13.5% and the 1-year mortality rate was 21.8%. A strong inverse relationship between the average annual volume of AMI cases treated by the admitting physician and mortality after an AMI was observed. The 30-day risk-adjusted mortality rate was 15.3% for physicians who treated 5 or fewer AMI cases per year (lowest quartile) compared with 11.8% for physicians who treated more than 24 AMI cases annually (highest quartile; P<.001). The 1-year risk-adjusted mortality rate was 24.2% for physicians who treated 5 or fewer AMI cases per year (lowest quartile) compared with 19.6% for physicians who treated more than 24 AMI cases annually (highest quartile; P<.001). CONCLUSION: Patients with AMI who are treated by high-volume admitting physicians are more likely to survive at 30 days and 1 year.  相似文献   

4.
BACKGROUND: Studies of career and parenting satisfaction have focused separately on medical students, residents and practising physicians. The objective of this study was to compare satisfaction across a spectrum of stages of medical career. METHODS: A survey of incoming medical students, current medical students, residents and physician teachers at the University of Saskatchewan was conducted in the spring of 1997. Response rates were 77% (43/56), 81% (177/218), 65% (134/206) and 39% (215/554) respectively. Factors assessed in the stepwise regression analysis were the effect of sex, parenting and level of training on the likelihood of recommending parenting to medical students or residents, and on parenting dissatisfaction, job dissatisfaction, career dissatisfaction and the importance of flexibility within the college program to accommodate family obligations. RESULTS: More male than female physician teachers had partners (92% v. 81%, p < 0.01) and were parents (94% v. 72%, p < 0.01). Female physician teachers spent equal hours per week at work compared with their male counterparts (mean 52 and 58 hours respectively) and more than double the weekly time on family and household work (36 v. 14 hours, p < 0.01). Physician teachers were the most likely respondents to recommend parenting to residents and their peers. Residents were the most dissatisfied with their parenting time. At all career stages women were less likely than men to recommend parenting, were more dissatisfied with the amount of time spent as parents and were more likely to regard flexibility within the college program as beneficial. There were no sex-related differences in job dissatisfaction and career dissatisfaction. However, married women were more dissatisfied with their jobs than were married men. Job dissatisfaction was greatest among medical students, and career dissatisfaction was greatest among residents. INTERPRETATION: The optimal timing of parenthood appears to be upon completion of medical training. Women were less likely to recommend parenting, less satisfied with the time available for parenting and more likely to value flexibility within the college program to accommodate family needs. These differences did not translate into women experiencing more job or career dissatisfaction.  相似文献   

5.
BACKGROUND: Research suggests that women have higher mortality after acute myocardial infarction (AMI) than men. Potential factors to explain this disparity include delay to presentation, less aggressive interventional strategies, and more severe disease at coronary angiography in women. METHODS: Consecutive patients (n=663) presenting to coronary care between Jan 2002 and Jan 2005 with ischemic type chest pain and AMI (troponin T >0.09ng/ml) were recruited. Details of the presentation and management were obtained from the medical notes. The primary endpoint was three month all cause mortality. RESULTS: Of these patients 31% (205/663) were female. Mean age of women was 70 (SD 11) and 63 (SD 13) for men (p<0.001). There was no difference between the sexes for delay in presentation or treatment or for ST elevation infarction site. Women had prior hypertension more than men (49% 100/205 vs. 38% 174/458, p=0.008). Women were less likely to have diagnostic catheterisation (67% 137/205 vs. 80% 365/458 p<0.001). Both genders had similar coronary artery disease extent and frequencies of LV impairment (EF<45%) and were equally likely to undergo revascularisation (79% 108/137 vs. 81% 295/365 p=NS). There was an excess 3 month mortality among women (11% 23/205 vs. 5% 24/458 in men p=0.006). INDEPENDENT: predictors of 3 month mortality by logistic regression analysis were age (OR 1.06, 95% CI 1.03 -1.09, p<0.001) and LV impairment (OR 0.28, 95% CI 0.13-0.56, p<0.001). CONCLUSION: As LV impairment was comparable in men and women, the excess mortality identified is due to older age at presentation of women.  相似文献   

6.
OBJECTIVE: To explore attitudes of new-to-practice certified family physicians in Ontario concerning sanctions against sexual abuse of patients by physicians and to assess the importance of concern about accusations of sexual abuse in influencing clinical decisions. DESIGN: Qualitative study and cross-sectional survey. SETTING: Ontario. PARTICIPANTS: Focus groups: 34 physicians who completed family medicine residency training between 1984 and 1989 participated in seven focus groups between June and October 1992. Survey: all certificants of the College of Family Physicians of Canada who received certification between 1989 and 1991 and were currently practising in Ontario. Of the 564 eligible physicians 395 (184 men and 211 women) responded, for an overall response rate of 70.0%. The response rates among the male and female physicians were 70.5% and 69.6% respectively. OUTCOME MEASURES: Physicians' attitudes toward restricting physical examinations done by physicians to same-sex patients, mandatory reporting of sexual impropriety and loss of licence in cases of sexual violation and the perceived importance of concern about accusations of sexual abuse as an influence on clinical decisions. RESULTS: During the focus groups male physicians in particular expressed concerns about the effect on their practice patterns of the current climate regarding sexual abuse of patients. Female physicians were less concerned about possible accusations of sexual abuse but expressed concerns regarding possible sexualization of the clinical encounter by male patients. In the survey equal proportions of men (163 [93.7%]) and women (191 [92.3%]) disagreed with restricting examinations to same-sex patients. The women were more likely than the men to agree that all suspected cases of sexual impropriety committed by other physicians should be reported (121 [58.7%] v. 86 [50.0%]), whereas the men were more likely to disagree (48 [27.9%] v. 32 [15.5%]) (p = 0.008). The women were also more likely than the men to agree that physicians should lose their licence permanently if they were found guilty of sexual violation (125 [62.2%] v. 73 [43.5%]), whereas the men were more likely to disagree (61 [36.3%] v. 37 [18.4%]) (p < 0.001). Almost half of the men (80 [46.5%]) but only 28 women (14.1%) reported that concerns about accusations of sexual abuse were of importance in their clinical decisions (p < 0.001). CONCLUSIONS: Young female family physicians practising in Ontario are much more likely than their male counterparts to endorse permanent loss of licence for physicians who sexually abuse patients and are significantly less concerned about accusations against themselves. Neither sex endorses only same-sex examinations by physicians. Educational approaches to protect patients while ensuring that appropriate care continues to be delivered are essential.  相似文献   

7.
OBJECTIVE: To examine the extent to which physician's sex explains variation in the activity level and service intensity of a cohort of physicians in each of five medical fields after other sources of variation are taken into account. DESIGN: Data from the Ontario Ministry of Health (MOH) and the CMA were analysed by means of multivariate regression techniques for panel data. SETTING: Ontario. PARTICIPANTS: A total of 137 dermatologists, 974 general internists, 330 pediatricians and 941 psychiatrists and a random sample of 2771 family physicians and general practitioners who met the eligibility criteria. Physicians were eligible if they billed the MOH for at least three quarters in 1983, did not bill as a medical laboratory director, provided direct patient care, did not have an alternative funding arrangement with the MOH, remained in the same specialty throughout the study period (1983-90) and billed from an Ontario address. OUTCOME MEASURES: Three measures of total activity level (annual number of services provided, annual fee-for-service billings and annual mean number of patients seen per quarter) and one measure of service intensity (annual mean number of services per patient per quarter). RESULTS: Although several variables (e.g., full-time work status, age, type of practice and recent practice move) influenced the four measures examined, physician's sex contributed significantly to explaining variation in activity in 70% of the regression equations. The women provided 33.0% fewere services per year than the men in family and general practice (p < 0.001), 25.0% fewer services in general internal medicine (p < 0.01), 22.1% fewer services in pediatrics (p < 0.05) and 22.3% fewer services in psychiatry (p < 0.001). Total billings by the women in these fields were also significantly less than those of their male colleagues, the difference being greatest among the family physicians and general practitioners (28.0%) and the general internists (27.0%) (p < 0.001). The women in these four fields saw significantly fewer patients per quarter than their male colleagues, the difference being greatest in psychiatry (33.0%) (p < 0.001). Sex affected service intensity in three fields. The female psychiatrists (14.8%) (p < 0.001) and general intenists (5.5%) (p < 0.10) provided more services per quarter than their male colleagues, whereas the female family physicians and general practitioners delivered 2.2% fewer services per patient per quarter than their male colleagues (p < 0.01). In two specialties differences between women aged 40 years or less and those over 40 years were observed. In general internal medicine the younger women had higher activity levels than the older women (p < 0.01). Conversely, in dermatology the younger women had lower activity levels (p < 0.05) and provided fewer services per patient per quarter (p < 0.001) than the older women. CONCLUSIONS: Although physician's sex explained much of the variation in activity level and service intensity, even after other important correlates were controlled for, the type and extent of differences observed between female and male physicians depended on the particular medical field examined. To understand the effect of the large increase in the number of women on the physician workforce, more detailed analyses by medical field are needed of the volume, mix and intensity of services provided by men and women, with adjustment for any possible differences in the patients seen in their practices.  相似文献   

8.
CONTEXT: Women with coronary artery disease (CAD) are believed to have a higher risk for adverse outcomes than men after conventional coronary interventions. The increasing use of coronary stenting has improved the outcome of patients undergoing coronary interventions, but little is known about the nature of outcomes in men vs women after this procedure. OBJECTIVE: To examine whether there are sex-based differences in prognostic factors and in early and late outcomes among CAD patients undergoing coronary stent placement. DESIGN, SETTING, AND PATIENTS: Inception cohort study, at 2 tertiary referral institutions in Germany. Consecutive series of 1001 women and 3263 men with symptomatic CAD who were treated with stenting between May 1992 and December 1998. Patients who underwent stenting in the setting of acute myocardial infarction were excluded. MAIN OUTCOME MEASURE: The combined event rates of death and nonfatal myocardial infarction, assessed at 30 days and 1 year after stenting and compared by sex. RESULTS: Compared with men, women undergoing coronary stenting were significantly older (mean age, 69 vs 63 years) and more likely to present with diabetes, arterial hypertension, or hypercholesterolemia. Women had less extensive CAD, a less frequent history of myocardial infarction and better preserved left ventricular function than men. Women presented an excess risk of death or nonfatal myocardial infarction only during the early period after stenting: the 30-day combined event rate of death or myocardial infarction was 3.1% in women and 1.8% in men (P =.02) and the multivariate-adjusted hazard ratio (HR) for women was 2.02 (95% confidence interval [CI], 1.27-3.19). At 1 year, the outcome was similar for both women and men (combined event rate for women, 6.0%, and for men, 5.8% (P =.77); multivariate-adjusted HR for women, 1.06 [95% CI, 0.75-1.48]). There was a sex difference in the prognostic value of baseline characteristics: the strongest prognostic factors were diabetes in women and age in men. CONCLUSIONS: The results of this study indicate that 1-year outcomes of women with CAD undergoing coronary artery stenting are similar to those of men. Despite the similarity in outcomes, there are several sex-specific differences in baseline characteristics, clinical course after the intervention, and relative weight of prognostic factors. JAMA. 2000;284:1799-1805.  相似文献   

9.
Compliance with screening mammography. Survey of primary care physicians   总被引:1,自引:0,他引:1  
A survey of primary care physicians in the greater Tampa Bay metropolitan area was conducted to determine compliance with screening mammography and associated physician characteristics. Information requested included their age, sex, specialty, and board certification status, and the ages and frequencies that they recommend screening mammography for their patients. A total of 565 physicians responded. Even though 88% indicated they follow American Cancer Society recommendations when advising screening mammography, only 62% were actually in full compliance. A significantly greater percentage of obstetricians/gynecologists were compliant (74%) compared to other specialties (family practice, 57%, p = .006; internal medicine, 56%, p = .007; general practice, 53%, p = .003). Women physicians were more likely to be compliant than men (83% versus 58%, p less than .001), and younger physicians more likely than older physicians (72% versus 49%, p less than .001). There was no significant difference in compliance rates between board certified and noncertified physicians.  相似文献   

10.
目的 分析影响两性患者急性心肌梗死(AMI)住院期间死亡风险的因素,为今后针对不同性别患者急性心肌梗死的防治提供依据.方法 收集2009年1月1日-2010年12月31日因AMI住我院心内科的689例AMI患者的临床资料,按性别分成两组,其中女性214例,男性475例,分析两性患者AMI的特点并对影响住院期间死亡的因素进行Logistic回归分析.结果 整个AMI人群男女比例为2.22:1,两性患者对比有如下特点:①女性较男性平均发病年龄大约晚10年;②女性接受再灌注治疗比率(41.6%)低于男性(59.2%),P<0.05;③女性AMI患者合并基础疾病种类较男性多,女性平均为(3.46 ±1.80)种,男性为(2.58±1.78)种,P<0.05;④女性患者发生严重并发症的发病率较男性高(7.5%与3.4%,P<0.05),住院期间死亡率(24.8%)也远高于男性(11.6%),P<0.05;⑤对住院期间死亡风险的Logistic回归分析,得出两性患者住院期间死亡风险的Logistic回归模型:女性为P=e-2.452-2.73 ×TREAT+0.695×HF +3.529×COMP/1+e-2.452-2.73×TREAT+0.695×HF +3.529×COMP,男性为:P=e-5.040+1.892×COPD+2.384×CRF+1.013Xhf+5.326×COMP/1+e5.040+1.892×COPD+2.384×CRF+1.013Xhf+5.326×COMP.结论 女性急性心肌梗死患者发病年龄大,并发症多,死亡率高;本研究得出的两性急性心肌梗死住院期间死亡风险的Logistic回归模型表明,女性患者住院期间接受再灌注治疗可降低住院期间死亡风险,再灌注治疗对男性患者则未能降低死亡风险;男性患者合并慢性阻塞性肺疾病、慢性肾功能不全及并发症住院期间死亡风险显著升高,而在女性患者却无类似影响;不论男女出现并发症如心功能不全、心源性休克、恶性心律失常及机械性并发症,住院期间死亡概率明显升高.  相似文献   

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