Influence of inpatient service specialty on care processes and outcomes for patients with non-ST-segment elevation acute coronary syndromes

被引:30
作者
Roe, Matthew T.
Chen, Anita Y.
Mehta, Rajendra H.
Li, Yun
Brindis, Ralph G.
Smith, Sidney C., Jr.
Rumsfeld, John S.
Gibler, W. Brian
Ohman, E. Magnus
Peterson, Eric D.
机构
[1] Duke Clin Res Inst, Durham, NC 27705 USA
[2] Duke Univ, Med Ctr, Durham, NC USA
[3] Univ Michigan, Dept Biostat, Ann Arbor, MI 48109 USA
[4] San Francisco Med Ctr, San Francisco, CA USA
[5] Univ N Carolina, Sch Med, Chapel Hill, NC USA
[6] Univ Colorado, Hlth Sci Ctr, Div Cardiol, Denver Vet Affairs Med Ctr, Denver, CO 80262 USA
[7] Univ Cincinnati, Coll Med, Cincinnati, OH USA
关键词
coronary disease; patients; patient care; medical specialties; guidelines;
D O I
10.1161/CIRCULATIONAHA.107.697003
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Background-Since the broad dissemination of practice guidelines, the association of specialty care with the treatment of patients with acute coronary syndromes has not been studied. Methods and Results-We evaluated 55 994 patients with non -ST-segment elevation acute coronary syndromes ( ischemic ST-segment changes and/or positive cardiac markers) included in the CRUSADE ( Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Quality Improvement Initiative from January 2001 through September 2003 at 301 tertiary US hospitals with full revascularization capabilities. We compared baseline characteristics, the use of American College of Cardiology/American Heart Association guidelines class I recommendations, and in-hospital outcomes by the specialty of the primary in-patient service ( cardiology versus noncardiology). A total of 35 374 patients (63.2%) were primarily cared for by a cardiology service, and these patients had lower-risk clinical characteristics, but they more commonly received acute (<= 24 hours) medications, invasive cardiac procedures, and discharge medications and lifestyle interventions. Acute care processes were improved when care was provided by a cardiology service regardless of the propensity to receive cardiology care. The adjusted risk of in-hospital mortality was lower with care provided by a cardiology service ( adjusted odds ratio 0.80, 95% confidence interval 0.73 to 0.88), and adjustment for differences in the use of acute medications and invasive procedures partially attenuated this mortality difference ( adjusted odds ratio 0.92, 95% confidence interval 0.83 to 1.02). Conclusions-Non-ST-segment elevation acute coronary syndrome patients primarily cared for by a cardiology inpatient service more commonly received evidence-based treatments and had a lower risk of mortality, but these patients had lower-risk clinical characteristics. Results from the present analysis highlight the difficulties with accurately determining how specialty care is associated with treatment patterns and clinical outcomes for patients with acute coronary syndromes. Novel methodologies for evaluating the influence of specialty care for these patients need to be developed and applied to future studies.
引用
收藏
页码:1153 / 1161
页数:9
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