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Titolo:
Does physician specialty affect the survival of elderly patients with myocardial infarction?
Autore:
Frances, CD; Shlipak, MG; Noguchi, H; Heidenreich, PA; McClellan, M;
Indirizzi:
Univ Calif San Francisco, Dept Med, San Francisco, CA USA Univ Calif San Francisco San Francisco CA USA Med, San Francisco, CA USA Stanford Univ, Dept Med, Stanford, CA 94305 USA Stanford Univ Stanford CAUSA 94305 niv, Dept Med, Stanford, CA 94305 USA
Titolo Testata:
HEALTH SERVICES RESEARCH
fascicolo: 5, volume: 35, anno: 2000,
parte:, 2
pagine: 1093 - 1116
SICI:
0017-9124(200012)35:5<1093:DPSATS>2.0.ZU;2-O
Fonte:
ISI
Lingua:
ENG
Soggetto:
COOPERATIVE CARDIOVASCULAR PROJECT; INSTRUMENTAL VARIABLES; IMMEDIATE ANGIOPLASTY; PRACTICE GUIDELINES; MEDICARE PATIENTS; CLINICAL-TRIALS; TERM MORTALITY; CARE; GENERALIST; OUTCOMES;
Keywords:
acute myocardial infarction; mortality; cardiovascular treatment effects; instrumental variables methods;
Tipo documento:
Article
Natura:
Periodico
Settore Disciplinare:
Social & Behavioral Sciences
Clinical Medicine
Citazioni:
32
Recensione:
Indirizzi per estratti:
Indirizzo: Frances, CD Vet Affairs Med Ctr, Room 111A1,4150 Clement St, San Francisco, CA 94121 USA Vet Affairs Med Ctr Room 111A1,4150 Clement St San FranciscoCA USA 94121
Citazione:
C.D. Frances et al., "Does physician specialty affect the survival of elderly patients with myocardial infarction?", HEAL SERV R, 35(5), 2000, pp. 1093-1116

Abstract

Objective. To determine the effect of treatment by a cardiologist on mortality of elderly patients with acute myocardial infarction (AMI, heart attack), accounting for both measured confounding using risk-adjustment techniques and residual unmeasured confounding with instrumental variables (TV) methods. Data Sources/Study Setting. Medical chart data and longitudinal administrative hospital records and death records were obtained for 161,558 patients aged greater than or equal to 65 admitted to a nonfederal acute care hospital with AMI from April 1994 to July 1995. Our principal measure of significant cardiologist treatment was whether a patient was admitted by a cardiologist. We use supplemental data to explore whether our analysis would differsubstantially using alternative definitions of significant cardiologist treatment. Study Design. This retrospective cohort study compared results using leastsquares (LS) multivariate regression with results from IV methods that accounted for additional unmeasured patient characteristics. Primary outcomes were 30-day and one-year mortality, and secondary outcomes included treatment with medications and revascularization procedures. Data Collection/Extraction Methods. Medical charts for the initial hospital stay of each AMI patient underwent a comprehensive abstraction, includingdates of hospitalization, admitting physician, demographic characteristics, comorbid conditions, severity of clinical presentation, electrocardiographic and other diagnostic test results, contraindications to therapy, and treatments before and after AMI. Principal Findings. Patients admitted by cardiologists had fewer comorbid conditions and less severe AMIs. These patients had a 10 percent (95 percent CI: 9.5-10.8 percent) lower absolute mortality rate at one year. After multivariate adjustment with LS regression, the adjusted mortality differencewas 2 percent (95 percent CI: 1.4-2.6 percent). Using IV methods to provide additional adjustment for unmeasured differences in risk, we found an even smaller, statistically insignificant association between physician specialty and one-year mortality, relative risk (RR) 0.96 (0.88-1.04). Patients admitted by a cardiologist were also significantly more likely to have a cardiologist consultation within the first day of admission and during the initial hospital stay, and also had a significantly larger share of their physician bills for inpatient treatment from cardiologists. IV analysis of treatments showed that patients treated by cardiologists were more likely to undergo revascularization procedures and to receive thrombolytic therapy, aspirin, and calcium channel-blockers, but less likely to receive beta-blockers. Conclusions. In a large population of elderly patients with AMI, we found significant treatment differences but no significant incremental mortality benefit associated with treatment by cardiologists.

ASDD Area Sistemi Dipartimentali e Documentali, Università di Bologna, Catalogo delle riviste ed altri periodici
Documento generato il 02/04/20 alle ore 02:50:50