24年来心房颤动临床病例的回顾性分析

心房颤动（房颤）是目前临床上最常见的心律失常，并且有很高的致残率和病死率。在房颤的住院病人中，风湿性心脏病（风心病）曾被认为是导致房颤的主要病因，近年来风心病的发病率已经大大下降，风心病可能已不再是房颤的主要原因，但是关于这方面的统计资料相对较少。此外，在房颤的治疗策略上，以前强调恢复窦性心律，现在认为对于持续性房颤可以采取控制心室率联合抗凝方法，但这一观念的转变是否能在临床上得到有效的实施不清楚。为此，查阅从1981年1月至2004年12月临床资料相对完整的房颤住院病例，以8年为一个时间段进行统计分析，对24年来房颤的病因和治疗情况进一步了解，为房颤的临床防治提供参考。     

Differences in medicare expenditures during the last 3 years of life

OBJECTIVE: To examine age, gender, race, and area income differences in Medicare expenditures in the 3 years before death. DESIGN: Cross-sectional study. PARTICIPANTS: A random sample of aged Medicare beneficiaries who died 1996 to 1999, N = 241,047. MEASURES: We estimate differences in mean Medicare expenditures by year before death and by age, gender, race, and area income, adjusting for comorbidities and Medicaid enrollment. RESULTS: Expenditures for blacks are lower in the second and third years before death and are not significantly different from whites in the last year of life (LYOL) (y3 = 70%, P <.0001; y2 = 82%, P <.0001; LYOL = 119%, P =.098). Differences in expenditures between decedents with area incomes over $35,000 compared to under $20,000 attenuate by the LYOL (y3 = 116%, P <.0001; y2 = 107%, P <.0001; LYOL = 96%, P <.0001). Expenditure patterns for women versus men vary by age. Among the younger cohorts (68 to 74 and 75 to 79), expenditures are higher for women in all 3 years before death. This difference attenuates among older cohorts; in the oldest cohort (90+), expenditures for men exceed those for women by 11% in the LYOL (P <.0001). Older beneficiaries have higher expenditures in the second and third years before death but lower expenditures in the LYOL. On average, the youngest cohort expended $8,017 more in the LYOL relative to the oldest cohort, whereas in the third year before death, the oldest cohort's expenditures were $5,270 more than those for the youngest cohort (P <.0001). CONCLUSIONS: Age-associated differences in aggregate Medicare payments for end-of-life care are more substantial than other differences. The fact that other differences attenuate in the LYOL may reflect having overcome barriers to health care, or reflect an effective ceiling on the opportunities to provide services for persons with overwhelming illness.