【争议】心脏病医师离开临床去参加学术会议，患者反而因此获益？

美国高风险心脏病患者接受的高强度照护反而会伤害他们？一项不同寻常的研究针对心脏病学术会议的时间进行了分析，得到了令人意想不到的结果。美国数千名高水平心脏病学家每年都会离开临床，去参加美国最重要的两个心脏病会议中的一个，而在此期间，患者的结局得到改善。

哈佛大学的Dr. Anupam B. Jena及其他研究者应用Medicare医疗保险的数据评估了2002-2011年间因心搏骤停、心力衰竭或急性心肌梗死入院患者的死亡率。他们重点评估了ACC年会（每年3月）或AHA年会（每年11月）期间入院的患者。

为了更好地进行对照分析，研究者使用了这两个会议召开前3周至后3周入院患者的数据，共涉及大约11,000例心搏骤停患者、近134,000例心力衰竭患者以及约60,000例急性MI的患者：每种疾病类别中，约14%的患者是在会议期间入院，其余86%（对照组）则是在非会议期间入院。

研究发现了一些统计学显著差异，表明在会议期间，即许多心脏病学家离开医院时，患者的表现反而较好。这种情况仅发生在教学医院以及死亡风险较高的住院患者中。对数据进行校正后，研究者发现，非教学医院或死亡风险较低的住院患者与教学医院或死亡风险较高的住院患者的结局并无显著差异。

该研究12月22日在线发表于JAMA Intern Med杂志 [doi:10.1001/jamainternmed.2014.6781]。研究报告称，对基线风险因素差异进行校正后的分析表明，在控制时间段因心搏骤停收入教学医院的患者的30日死亡率为69%，会议期间为59%；在控制时间段心力衰竭患者的30日死亡率为25%，会议期间为18%。

对于因急性心衰入住教学医院的患者而言，重大会议期间与非会议期间收治患者的30日死亡率并无显著差异，不过相似的死亡率是在两个时间段行PCI术患者数量有显著差异的基础上产生的：重大会议期间，21%的急性MI患者行PCI；而非会议期间该患者比例则多达28%。

Dr. Jena总结称：“这种发现有一种解释，就是会议期间对患者的照护强度较低，而对于高风险心血管疾病患者，照护带来的伤害可能会超过获益”。

加利福尼亚大学的Dr. Rita F. Redberg是JAMA国际医学的一位编辑，她在该研究的编者按中表述了一种看似合理的解释，“对存在心力衰竭或心搏骤停的高风险患者的干预越多，死亡率就会越高”。Redberg总结道：“多数患者的结局并未因为许多心脏病学家离开临床而变糟，这令人感到放心。更重要的是，这个分析可能会指导我们在一年内所有时间段降低死亡率”。

这个发现引人关注并令人吃惊，但该结果是否应引起重视？至少有一位专家表示至少应重视该结果并开展进一步的研究。是否有人会接受挑战并去深入探讨这种关系？是否有人愿意尝试将“教学医院的心脏病学专家不在临床的保护性效果”应用至全年所有时间？这值得关注。如果真有一种药物对死亡率有如此 效果，制药行业肯定会为之狂热。

Can the high-intensity care given acutely ill, high-risk U.S. patients with cardiac disease actually harm them?

Results from an unusual analysis of cardiology-meeting times seem to suggest that sobering possibility. Patient outcomes improved when thousands of high-level, American cardiologists left their practices for a few days each year to attend either of the two major U.S. heart disease meetings.

Researchers led by Dr. Anupam B. Jena of Harvard University, Boston, used Medicare data to examine mortality rates among patients hospitalized for cardiac arrest, heart failure, or acute myocardial infarction during 2002-2011. They focused on patients admitted during the annual meetings of the American College of Cardiology (usually in March) or the American Heart Association (during November).

As controls in their case-control analyses, they used data from patients admitted on similar days of the week during the 3 weeks immediately before or after these two meetings. This gave them roughly 11,000 total patients with cardiac arrest, nearly 134,000 with heart failure, and about 60,000 with acute MI – about 14% of patients in each disease category admitted during a meeting and the other 86% (controls) admitted when there was no meeting.

The results showed some statistically significant differences indicating that patients did better during the meetings, presumably when many cardiologists were away from their hospitals. These associations only occurred at teaching hospitals and among patients at high risk for inpatient mortality. The investigators saw no statistically significant differences, after adjustment, in mortality during meetings among patients treated at nonteaching hospitals or among patients with a low risk for inpatient mortality.

In analyses that adjusted for baseline differences in risk factors, the 30-day mortality rate for patients admitted to teaching hospitals with cardiac arrest was 69% during control dates and 59% during the meetings. Thirty-day mortality for patients admitted with heart failure was 25% during control dates and 18% during the meetings, researchers reported in an article published online on Dec. 22 (JAMA Intern. Med. 2014 [doi:10.1001/jamainternmed.2014.6781]).

Although 30-day mortality among patients admitted with an acute MI did not differ significantly at teaching hospitals between patients who presented during a major meeting and those who did not, the results showed that these similar mortality rates were achieved despite a statistically significant difference in the rate of percutaneous coronary interventions (PCI) that patients received: During the major meetings, 21% of the acute MI patients underwent PCI, but when a meeting was not in progress, the PCI rate jumped to 28% of all acute MI patients.

“One explanation for these findings is that the intensity of care provided during meeting dates is lower, and that for high-risk patients with cardiovascular disease, the harms of this care may unexpectedly outweigh the benefits,” Dr. Jena concluded.

An editor’s note published with the new report suggested a plausible explanation for the findings is that “more interventions in high-risk patients with heart failure and cardiac arrest leads to higher mortality.” In her note, Dr. Rita F. Redberg, a cardiologist at the University of California, San Francisco, and editor of JAMA Internal Medicine, concluded, “It is reassuring that patient outcomes do not suffer while many cardiologists are away. More important, this analysis may help us to understand how we could lower mortality throughout the year.”

It’s a remarkable and surprising finding, but can it be taken seriously? At least one expert said yes, at least seriously enough to warrant further study and consideration.

It will be interesting to see if anyone takes up the challenge to further explore this relationship and tries to find ways to apply throughout the year the protective effect of having fewer teaching-hospital cardiologists around. If a drug had this beneficial effect on mortality, the pharmaceutical industry would be all over it.

Copyright (c) 2014 Frontline Medical News, a Frontline Medical Communications, Inc. company. All rights reserved. This material may not be published, broadcast, copied or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications, Inc.