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station怎么读CORRESPONDENCE Syncope and NAMCS
To the Editor:—Our interest in emergency department(ED) patients with syncope drew our attention to the recent article by Dr.Sun et al.1The results were concerning and we believe the data prented rai issues regarding the validity of the study and the survey upon which it is bad.
Our primary concern is the u of the National Ambula-tory Medical Care Survey(NAMCS).The retrospective data from this survey have been ud by veral rearchers.The results generated from the survey in the past have made some investigators question the validity of the survey and its data-collection techniques.2Sun et al.have ud NAMCS on two occasions to evaluate care of ED patients:one on admission patterns of patients with syncope and another on electrocardiogram(ECG)u and syncope.1,3The results and conclusions of both studies are discordant from our experience and what we have found in prospective data collection.The differences are more than one could explain from the fact that our data come from a single tertiary care hospital,and defy the real-world experience and common n of most readers.
Consider the following differences between Sun et al.’s results and the results of clo to1,400concutive patients prospectively evaluated for syncope4,5:overall admission rate,32%vs.56%;admission rate for elder patients more than80years old,58%vs.78%;and patients evaluated with ECGs,56%vs.93%.Sun et al.claim that the results may be reasonable when compared with the results of European studies,but in no way can the studies be ud to illustrate the standard of care in the United States.Further-more,from Table4in the Sun article,it is impossible to believe that only60%of patients with documented cardiac ischemia and syncope were admitted!It is hard to consider that discharge of any of the patients would occur at any U.S.hospital.
In the United States we believe that,in general,all patients with known cardiac ischemia get admitted,most patients with syncope get ECGs,and a greater proportion of patients(especially older patients)get admitted when they prent to the ED with syncope.Sun et al.’s article is helpful in that it confirms previous suspicion that the NAMCS,with its retrospective design and chart-review techniques,provides incomplete data and is likely misleading.We truly hope that the study results are becau of missing or poor data collection,and not indicative of the actual performance of emergency physicians.—James Quinn,MD,MS(quinnj@ stanford.edu),Departments of Surgery and Emergency Medicine,Stanford University,Stanford,CA;and Daniel McDermott,MD,Department of Medicine,University of California,San Francisco,San Francisco,CA
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doi:10.1197/j.aem.2004.11.009
References
1.Sun BC,Emond JA,Camargo CA Jr.Characteristics and
admission patterns of patients prenting with syncope totake control
ncy departments,1992–2000.Acad Emerg Med.英文翻译法文
2004;11:1029–34.2.O’Brien C,Milzman D.NHAMCS:quality of a national
emergency department-bad information system questioned [letter].Acad Emerg Med.1999;6:666–8.
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3.Sun BC,Emond JA,Camargo CA Jr.Inconsistent
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electrocardiographic testing for syncope in United States
emergency departments.Am J Cardiol.2004;93:1306–8.
4.Quinn JV,Stiell IG,McDermott DA,Sellers KL,Kohn MA,
Wells GA.Derivation of the San Francisco Syncope Rule to predict patients with short-term rious outcomes.Ann
Emerg Med.2004;43:224–32.
5.Quinn JV,McDermott DA,Stiell IG.Validation of the
San Francisco Syncope Rule[abstract].Acad Emerg Med.
帽子戏法 英文2004;11:529–30.
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In reply:—We thank Drs.Quinn and McDermott for their interest in our work.Using data from the National Hospital Ambulatory Medical Care Survey(NHAMCS),we have reported variance in electrocardiogram(ECG)testing by age,1as well as high discharge rates for elders and patients with concurrent heart dia.2
Quinn and McDermott are concerned about the face validity of ourfindings.We assume their critiques are of NHAMCS,rather than of the National Ambulatory Medical Care Survey(NAMCS).NHAMCS is
a federal survey of visits to emergency departments(EDs)and hospital-bad clinics; NAMCS is a federal survey of visits to office-bad physi-cians.We ud data from NHAMCS.
Quinn and McDermott are surprid that data from a national survey of usual ED practice differ from data from their single-center,tertiary care,rearch cohort at the University of California,San Francisco.Although we ap-preciate the value of personal experience,we believe that data from a random sample of nearly500EDs in NHAMCS provide more generalizable insights into practice patterns. Moreover,Quinn and McDermott appear to categorically reject NHAMCS data bad on the survey’s cross-ctional design;surprisingly,they offer no specific insights about how bias might have been introduced into our estimates.We previously explored the possibility of bias from miscoding of chief complaint,ECG documentation,and concurrent cardiac diagnos.Missing disposition data are unlikely to bias our findings:less than1%of all syncope patients had an unknown disposition;for example,0.8%of patients over the age of80 years and0%of patients with a concurrent International Classification of Dias,Ninth Revision(ICD-9)cardiac diagnosis had an unknown disposition.We refer readers back to our original articles for a complete discussion of nsitivity analys and limitations:we are confident that our results are valid in the context of the NHAMCS study design.Indeed, our estimates for overall admission rates,admission rates for elders,and ECG testing rates are within the ranges reported from a variety of practice ttings.3–9
Quinn and McDermott are specifically concerned about the face validity of thefinding that60%of NHAMCS syn-cope patients with documented acute,subacute,or chronic
ACAD EMERG MED d April2005,Vol.12,No.4d www.aemj381
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