中国省、市和县级医院ST段抬高型心肌梗死住院患者就诊时间差异和延迟就诊的相关因素分析

Factors Associated With Prolonged Time From Symptom Onset to Hospital Presentation for Patients With ST-elevation Myocardial Infarction in China

目的:比较我国省级、市级和县级三个级别医院ST段抬高型心肌梗死(STEMI)患者不同来院时间段的就诊情况,探讨延迟就诊的相关危险因素。方法:分析中国急性心肌梗死(CAMI)注册登记研究2013-01-01至2014-09-30期间107家医院收治的STEMI患者18536例,患者发病时间均在7天内;按发病到来院时间分为<3 h、3~6 h、6~12 h、12~24 h、≥24 h 5个时间段,比较省级、市级和县级三个级别医院收治患者的临床特征、治疗和预后情况,以≥12 h为标准,划分为延迟就诊和及时就诊,分析延迟就诊的相关危险因素。结果:18536例STEMI患者的平均年龄为(61.97±12.46)岁,男性患者占76.4%(14159/18536)。来院就诊时间<3 h、3~6 h、6~12 h、12~24 h、≥24 h 5个不同时间段的患者分别占总人群的比例为24.2%、26.7%、16.6%、10.3%、22.2%。延迟就诊患者占32.6%(6034/18536)。随着来院就诊时间的延长,年龄有增大趋势,无医疗保险、独自居住和文化水平低、killip心功能分级≥2级、保守治疗、死亡的比例有增加趋势,而男性患者、农村居住、早发冠心病、既往心肌梗死病史、使用急救医疗服务比例有下降趋势(P均<0.001)。多因素Logistic回归分析提示,年龄大(OR=1.007,95%CI:1.003~1.012,P=0.001),无医疗保险自费就诊(OR=1.328,95%CI:1.110~1.589,P=0.002)、文化水平低(小学/文盲)(OR=1.250,95%CI:1.132~1.381,P<0.001)、目前吸烟(OR=1.223,95%CI:1.032~1.449,P=0.020)是患者延迟就诊的独立危险因素。结论:在不同级别医院的不同来院就诊时间段,就诊情况存在差异。中国延迟就诊比例高。患者年龄大,无医疗保险、文化水平低、目前吸烟是患者延迟就诊的独立危险因素。

Objectives:To investigate factors responsible for the prolonged time from symptom onset to hospital presentation in patients with ST-segment elevation myocardial infarction(STEMI)admitted to provincial,city and county levels hospitals of China.Methods:This observational analysis was performed among 18536 patients with STEMI,who were documented in China Acute Myocardial Infarction(CAMI)Registry and treated in 107 hospitals between January 1st,2013 and September 30,2014.Patients were divided into five groups according to time from symptom onset to hospital presentation(<3 h,3-6 h,6-12 h,12-24 h,≥24 h).Prolonged time from symptom onset to treatment was defined as more than 12 hours Results:Among 18536 STEMI patients(mean age:[61.97±12.46]years,14159 males).Patients with prolonged time from symptom onset to treatment accounted for 32.6%(6034/18536).There were 24.2%,26.7%,16.6%,10.3%,22.2%patients in the five groups(<3 h,3-6 h,6-12 h,12-24 h,≥24 h).The prevalence of prolonged time from symptom onset to treatment was similar among patients admitted to county,city and provincial level hospitals.The rate of patients without medical insurance,living alone,rural residents,low level of cultural education,killip class≥2,drug therapy and death tend to increase in proportion with the increase on the time from symptom onset to treatment.Male patients,premature coronary heart disease,the history of myocardial infarction and the use of emergency medical services presented a downward trend(P<0.001)with the increase of the time from symptom onset to treatment.Multivariate logistic regression analysis indicated that the elderly patients(OR=1.007,95%CI:1.003-1.012,P=0.001),no medical insurance(OR=1.328,95%CI:1.110-1.589,P=0.002),lower education level(primary school or illiterate)(OR=1.250,95%CI:1.132-1.381,P<0.001),and current smoking(OR=1.223,95%CI:1.032-1.449,P=0.020)were independent risk factors of the prolonged time from symptom onset to treatment.Conclusions:The time from symptom onset to hospital presentation in significant different and the delayed time is similarly common in patients with STEMI admitted to provincial,city and county levels hospitals of China.The age,no medical insurance,lower education level(primary school or illiterate),and recent smoking are independent risk factors of the prolonged time from symptom onset to treatment in Chinese STEMI patients.