Certifying examination performance and patient outcomes following acute myocardial infarction

OBJECTIVE: To establish whether successful certifying examination performances of doctors are associated with their patients' mortality and length of stay following acute myocardial infarction. DESIGN: Risk adjusted mortality and survivors' length of stay were compared for doctors who had satisfactorily completed training in internal medicine or cardiology and attempted the relevant examination. Specifically, the study investigated the joint effects of hospital location, availability of advanced cardiac care, doctors' specializations, certifying examination performances, year certification was first attempted and patient volume. SETTING AND PARTICIPANTS: Data on all acute myocardial infarctions in Pennsylvania for the calendar year 1993 were collected by the Pennsylvania Health Care Cost Containment Council. These data were combined with physician information from the database of the American Board of Internal Medicine. RESULTS: Holding all variables constant, successful examination performance (i.e. certification in internal medicine or cardiology) was associated with a 19% reduction in mortality. Decreased mortality was also correlated with treatment in hospitals located outwith either rural or urban settings and with management by a cardiologist. Shorter stays were not related to examination performance but were associated with treatment by high volume cardiologists who had recently finished training and who cared for their patients in hospitals located outwith rural or urban settings. CONCLUSIONS: The results of the study add to the evidence supporting the validity of the certifying examination and lend support to the concept that fund of knowledge is related to quality of practice.     

The effect of diet and aspirin on patient outcome after myocardial infarction.

Recent studies show that diet and aspirin therapy inhibit platelet aggregation and may independently reduce complications and mortality in patients after acute myocardial infarction (AMI). To compare the effects of diet and aspirin, 140 patients, who were 4-6 wk post acute myocardial infarction, were assigned either to Group A (placebo with cardiovasoprotective diet) or Group B (aspirin [180 mg daily]) with fat-modified control diet in a single-blind controlled fashion. Of the 140 patients, 7 left the trial before it was completed. Of the remaining 133 patients, 68 in Group A and 65 in Group B were followed for one year. When the study began, the following factors were comparable for both groups: mean age, sex, risk factors, complications of myocardial infarction, electrocardiographic changes, and laboratory data. Group A received a significantly higher caloric intake (P less than 0.02) from complex carbohydrates, vegetable proteins, polyunsaturated fats, and larger amounts of dietary fibers, potassium, magnesium, and vitamin C compared with Group B, which received significantly larger amounts of saturated fats and cholesterol (P less than 0.01). The rehabilitation program, which included reduced smoking, increased exercise and drug therapy, was comparable in both groups. After one year, mean serum cholesterol (223.2 +/- 32.0 mg/dl) and triglyceride (156.2 +/- 13.5 mg/dl) levels in Group A, but not in Group B, were significantly (P less than 0.02) lower compared with mean serum cholesterol (241.2 +/- 39.5 mg/dl) and triglyceride (175.5 +/- 18.5 mg/dl) levels at the beginning of the study.(ABSTRACT TRUNCATED AT 250 WORDS)     

我国公立医院产权制度改革的战略选择

随着医疗体制改革的深化和医疗市场竞争的加剧，公立医院的产权改革势在必行。本文在结合公立医院管理经验和自身的特殊性的基础上，探讨了公立医院产权改革可能的发展战略。提出国有产权在现代医院管理制度中应该处于主导地位，产权改革的重点是减少国有资本的政策性负担和加强国有资本的影响力和控制力。     

院前急救护理路径在急性心肌梗死中的救治效果分析

目的探讨院前急救护理路径在急性心肌梗死救治中的应用效果。方法选取2018-06至2019-10在我院120站救治的136例急性心肌梗死患者资料进行回顾性分析,根据救治流程进行分组,实施常规急救流程的患者设置为对照组(n=61),院前急救护理路径指导下实施急救流程的患者设置为观察组(n=75),对比两组患者院前急救项目时间、救治效果及急救护理满意度。结果 (1)两组出诊反应时间及急救反应时间比较,差异无统计学意义(P>0.05),观察组现场救治时间、急诊室至首次球囊扩张时间及心肌总缺血时间均少于对照组,组间比较差异有统计学意义(P<0.05);(2)观察组院前急救人员到达时及治疗后症状缓解率、转运成功率以及急救成功率均高于对照组,各组间比较差异有统计学意义(P<0.05);(3)观察组心理护理、服务态度及总分高于对照组,各组间比较差异有统计学意义(P<0.05)。结论院前急诊救治急性心肌梗死时应用院前急救护理路径可缩短现场救治时间、急诊室至首次球囊扩张时间及心肌总缺血时间,提高救治效率及患者满意度,是提升院前急救水平的有效方法。通过培训、宣传等模式提高急性心肌梗死患者及家属自行救治水平,为患者心肌梗死争取宝贵的抢救时间十分重要。     

急性心肌梗死的院前救治

冠心病仍是经济发达国家的首要死亡病因,占死亡总数的40～50%,在我国的情况也属严重.急性心肌梗死的猝死率较高,据报导美国每年约有60万人死于急性心肌梗死,院外的猝死者占77%,多发生于病后2小时.故院前的救治是争取急性心肌梗死存活的关键因素之一.     

急性心肌梗死的院前救治

冠心病仍是经济发达国家的首要死亡病因,占死亡总数的40～50％,在我国的情况也属严重。急性心肌梗死的猝死率较高,据报导美国每年约有60万人死于急性心肌梗死,院外的猝死者占77％,多发生于病后2小时。故院前的救治是争取急性心肌梗死     

The risk of acute myocardial infarction after stopping drinking

BACKGROUND: Subjects at high risk of alcohol-related diseases may benefit from alcohol cessation. However, drinkers have a lower risk of acute myocardial infarction (AMI) than abstainers, and there is very scanty information on how the risk changes after stopping drinking. METHODS: Between 1995 and 1999, we administered a structured questionnaire to 507 cases (378 men, 129 women) with a first episode of nonfatal AMI and 478 control patients (297 men, 181 women) admitted to the same network of hospitals in the greater Milan area for acute conditions. RESULTS: Compared to lifelong abstainers, the odds ratio (OR) adjusted for age, sex, and several AMI risk factors was 0.56 (95% confidence interval [CI] 0.41-0.84) for current and 0.65 (95% CI 0.37-1.15) for former drinkers (48 cases and 44 controls). The OR was 2.10 (0.40-11.1) for having stopped since 1 year, 0.64 (95% CI 0.19-2.16) for 2-4 years, 0.46 (95% CI 0.18-1.20) for 5-14 years, and 0.78 (95% CI 0.27-2.27) for > or = 15 years. CONCLUSIONS: Although our data are too limited to draw any definite conclusion, they suggest that the protection of alcohol drinking against AMI may persist, at least in part, for several years after stopping.     

Quality indicators of hospital care: evaluation of patient care in acute myocardial infarction]

In the international hospital accreditation programs there is an increasing emphasis on involving performance indicators. The inpatient mortality rate of AMI patients and the usage of thrombolytic therapy are very common, evidence based indicators of these programs. The authors goal was to analyze the applicability of these indicators in the evaluation of the Hungarian hospital care. In Hungary, there is a data collection system on every inpatient case. This database was used to determine the above mentioned two indicators for 1997 and 1998. They calculated by hospital group level, by institutions and by geographic areas crude rates and rates adjusted for age and gender, and for severity using the different DRGs of AMI patients. In these two years the inpatient mortality rates of AMI patients were 20.4% and 21.7%, and the usage of thrombolytic therapy were 9.9% and 11.8%, respectively. Using indirect standardization methodology in the usage of thrombolytic therapy, they found high differences among the counties compared to the national average, the range was 51-199%, and among the institutions 0-306%, respectively. It is clear, that there are huge differences in the curative processes and in the inpatient mortality rates of AMI patients among the hospitals. The differences are developed by chance, there are no close connections either to hospital groups, or to geographical locations. Because of the difficulties of risk adjustment, they suggested that indicators were suitable for benchmarking. It is necessary to implement in the national quality criteria system different indicators for evaluating the patient care, to develop programs for auditing the best and worst hospitals and to introduce standards for assuring the validity of the basic data.     

Long-term anticoagulant treatment after acute myocardial infarction. The Warfarin Re-Infarction Study.

High levels of fibrinogen and clotting factor VII are associated with an increased risk for subsequent death and cardiovascular disease in apparently healthy individuals. Furthermore, pathoanatomic studies and coronary angiography have confirmed a relationship between coronary thrombus formation and acute Q-wave infarction. Effective antithrombotic agents may prevent or limit thrombus formation and events related to thrombosis. The Warfarin Re-Infarction Study (WARIS) studied the effect of warfarin in survivors of acute myocardial infarction. Patients aged 75 years or less were randomized in a double-blind, placebo-controlled study to test whether long-term treatment with warfarin reduces the risk of death, reinfarction, and thromboembolic morbidity. A total of 1918 patients were screened for participation; 1214 were recruited. The mean follow-up was 37 months. Analyzed on an intention-to-treat basis, 123 (20%) in the placebo group died, versus 94 (15%) in the warfarin group, a risk reduction of 24% (P = 0.026). Considering patients on treatment or within 28 days after discontinuing the test medication, 92 in the placebo group died, as compared with 60 of the warfarin-treated patients, a risk reduction of 35% (P = 0.005). Relapsing myocardial infarction (fatal and nonfatal) was reduced by 43% (P = 0.0001). The incidence of cerebrovascular attacks was lower in the warfarin group (16 patients) than the placebo group (41 patients), a highly significant reduction of 61% (P = 0.0003). Serious bleeding occurred in 11 patients taking warfarin, an incidence of 0.6% per year. In conclusion, long-term anticoagulant therapy may be recommended after acute myocardial infarction.     

RDW与急性心肌梗死预后的相关性研究

目的:研究红细胞分布宽度(RDW)与急性心肌梗死(AMI)患者心功能分级(Killip分级)的关系,以及与脑钠肽(BNP)和超敏C反应蛋白(hs-CRP)之间的相关性,从而探讨RDW在诊断AMI及判断预后中的作用。方法:回顾性分析了2006年12月-2009年12月入住我院的345例AMI患者,根据临床症状和肺部有无啰音、啰音范围和收缩压进行Killip分级。利用Simens-Bayer Advia 2120全血细胞分析仪、Triage全自动免疫分析系统、Olympus AU5421全自动生化分析仪分别检测患者的RDW、血红蛋白(Hb)、血细胞比容(HCT)、平均红细胞体积(MCV)、BNP以及hs-CRP等指标。分析Killip各级之间RDW的变化趋势,同时对RDW与BNP和hs-CRP之间的相关性进行分析。结果:Killip II级及以上患者的RDW值明显高于Killip I级患者的RDW(13.75 vs13.07,P<0.001),但Killip II级I、II级及IV级之间RDW的结果没有显著差异(P II/III=0.498、P II/IV=0.418、P III/IV=0.817),Killip...     

替罗非班对急性心肌梗死冠状动脉支架术后冠状动脉再狭窄的影响分析

目的研究替罗非班对急性心肌梗死冠状动脉支架术后冠状动脉再狭窄的影响。方法选取本院2009年1月-2011年1月收治的急性心肌梗死行PCI介入治疗者58例,随机分为观察组和对照组。均于PCI术后给予低分子肝素皮下注射,口服阿司匹林及氯吡格雷治疗。观察组患者在此基础上给予盐酸替罗非班氯化钠注射液静脉滴注24～36h。观察两组治疗前和治疗48h后血小板聚集率及PCI术后6个月冠状动脉再狭窄的发生率。结果观察组接受治疗48h后血小板聚集率显著低于治疗前,且显著低于对照组,差异有统计学意义（P〈0.01）;观察组术后6个月冠状动脉再狭窄发生率为6.9%,显著低于对照组的27.6%,差异有统计学意义（P〈0.05）。结论替罗非班能有效地减低急性心肌梗死PCI术后冠状动脉再狭窄,值得临床推广应用。     

Patient-reported outcomes as predictors of 10-year survival in women after acute myocardial infarction

Background  

Patient-reported outcomes are increasingly seen as complementary to biomedical measures. However, their prognostic importance has yet to be established, particularly in female long-term myocardial infarction (MI) survivors. We aimed to determine whether 10-year survival in older women after MI relates to patient-reported outcomes, and to compare their survival with that of the general female population.     

阿替普酶静脉溶栓治疗急性心肌梗死疗效观察

目的:探讨应用阿替普酶静脉溶栓治疗急性心肌梗死的临床疗效.方法:选取108例急性心肌梗死患者作为研究对象,随机分为两组,每组各54例.试验组采用阿替普酶静脉溶栓治疗,对照组常规采用尿激酶静脉溶栓治疗.对比观察两组患者的临床治疗效果.结果:试验组治疗总有效率显著高于对照组,差异具有统计学意义(P<0.05).结论:阿替普酶静脉溶栓在治疗急性心肌梗死中疗效显著,可在临床中推广和应用.     

Thrombolysis for acute myocardial infarction in a district general hospital.

We report our experience in establishing thrombolysis as a routine part of the management of patients with acute myocardial infarction in our hospital; with particular reference to the effectiveness of the policy, safety and delays in administration.     

The effect of hospital/physician integration on hospital choice

In this paper, we estimate how hospital ownership of physicians' practices affects their patients' hospital choices. We match data on the hospital admissions of Medicare beneficiaries, including the identity of their physician, with data on the identity of the owner of their physician's practice. We find that a hospital's ownership of a physician dramatically increases the probability that the physician's patients will choose the owning hospital. We also find that patients are more likely to choose a high-cost, low-quality hospital when their physician is owned by that hospital.