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[JAMA最新论文]:美国教学医院常见疾病的病死率较低
2017年06月14日 时讯速递, 进展交流 暂无评论

Original Investigation

May 23/30, 2017

Association Between Teaching Status and Mortality in US Hospitals

Laura G. Burke, Austin B. Frakt, Dhruv Khullar, et al.

JAMA. 2017; 317(20): 2105-2113. doi:10.1001/jama.2017.5702

Abstract

Importance 背景

Few studies have analyzed contemporary data on outcomes at US teaching hospitals vs nonteaching hospitals.

仅有很少的研究分析了美国教学医院与非教学医院患者预后的差异。

Objective 目的

To examine risk-adjusted outcomes for patients admitted to teaching vs nonteaching hospitals across a broad range of medical and surgical conditions.

对于多种内科与外科疾病,验证入住教学医院与非教学医院患者的风险校正预后。

Design, Setting, and Participants 设计,场景与研究人群

Use of national Medicare data to compare mortality rates in US teaching and nonteaching hospitals for all hospitalizations and for common medical and surgical conditions among Medicare beneficiaries 65 years and older.

使用全国Medicare数据以比较美国教学医院与非教学医院所有住院患者的病死率,以及罹患常见内科与外科疾病的65岁以上Medicare保险受益人临床预后

Exposures 暴露因素

Hospital teaching status: major teaching hospitals (members of the Council of Teaching Hospitals), minor teaching hospitals (other hospitals with medical school affiliation), and nonteaching hospitals (remaining hospitals).

医院教学状况:大的教学医院(教学医院理事会成员),小的教学医院(医学院附属的其他医院),以及非教学医院(其他医院)。

Main Outcomes and Measures 主要预后指标

Primary outcome was 30-day mortality rate for all hospitalizations and for 15 common medical and 6 surgical conditions. Secondary outcomes included 30-day mortality stratified by hospital size and 7-day mortality and 90-day mortality for all hospitalizations as well as for individual medical and surgical conditions.

主要预后指标为所有住院患者以及15种常见内科疾病和6种常见外科疾病患者的30天病死率。次要预后指标包括根据医院大小分层的30天病死率,所有住院患者及各种内科及外科疾病患者的7天及90天病死率。

Results 结果

The sample consisted of 21 451 824 total hospitalizations at 4483 hospitals, of which 250 (5.6%) were major teaching, 894 (19.9%) were minor teaching, and 3339 (74.3%) were nonteaching hospitals. Unadjusted 30-day mortality was 8.1% at major teaching hospitals, 9.2% at minor teaching hospitals, and 9.6% at nonteaching hospitals, with a 1.5% (95% CI, 1.3%-1.7%; P < .001) mortality difference between major teaching hospitals and nonteaching hospitals. After adjusting for patient and hospital characteristics, the same pattern persisted (8.3% mortality at major teaching vs 9.2% at minor teaching and 9.5% at nonteaching), but the difference in mortality between major and nonteaching hospitals was smaller (1.2% [95% CI, 1.0%-1.4%]; P < .001). After stratifying by hospital size, 187 large (≥400 beds) major teaching hospitals had lower adjusted overall 30-day mortality relative to 76 large nonteaching hospitals (8.1% vs 9.4%; 1.2% difference [95% CI, 0.9%-1.5%]; P < .001). This same pattern of lower overall 30-day mortality at teaching hospitals was observed for medium-sized (100-399 beds) hospitals (8.6% vs 9.3% and 9.4%; 0.8% difference between 61 major and 1207 nonteaching hospitals [95% CI, 0.4%-1.3%]; P = .003). Among small (≤99 beds) hospitals, 187 minor teaching hospitals had lower overall 30-day mortality relative to 2056 nonteaching hospitals (9.5% vs 9.9%; 0.4% difference [95% CI, 0.1%-0.7%]; P = .01).

样本包括4483所医院的21451824名住院患者,其中250所医院(5.6%)为大的教学医院,894所医院(19.9%)为小的教学医院,其余3339所医院(74.3%)为非教学医院。大的教学医院未校正30天病死率为8.1%,小的教学医院为9.2%,非教学医院为9.6%,大的教学医院与非教学医院病死率相差 1.5% (95% CI, 1.3%-1.7%; P < .001)。针对患者及医院特征进行校正后,上述趋势仍未改变(大的教学医院病死率8.3%,小的教学医院9.2%,非教学医院9.5%),但大的教学医院与非教学医院病死率差异减小 (1.2% [95% CI, 1.0%-1.4%]; P < .001)。对医院大小进行校正后,187所大的教学医院 (≥400张床位) 30天校正病死率较76所大的非教学医院更低(8.1% vs 9.4%; 差异1.2% [95% CI, 0.9%-1.5%]; P < .001)。中等大小的医院(100-399张床位)30天病死率也观察到同样的趋势 (8.6% vs 9.3% and 9.4%; 61所大的教学医院与1207所非教学医院差异 0.8%  [95% CI, 0.4%-1.3%]; P = .003)。在小医院 (≤99张床位)中,187所小的教学医院30天病死率较2056所非教学医院更低(9.5% vs 9.9%; 差异0.4% [95% CI, 0.1%-0.7%]; P = .01)。

Conclusions and Relevance 结论与意义

Among hospitalizations for US Medicare beneficiaries, major teaching hospital status was associated with lower mortality rates for common conditions compared with nonteaching hospitals. Further study is needed to understand the reasons for these differences.

在住院的美国Medicare保险受益人中,常见疾病患者入住大的教学医院病死率低于非教学医院。需要进行进一步的研究了解这一差异的原因。

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