Barnato Amber E, Chang Chung-Chou H, Saynina Olga, Garber Alan M
Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA 15213, USA.
J Gen Intern Med. 2007 Mar;22(3):338-45. doi: 10.1007/s11606-006-0088-x.
To examine inpatient intensive care unit (ICU) and intensive procedure use by race among Medicare decedents, using utilization among survivors for comparison.
Retrospective observational analysis of inpatient claims using multivariable hierarchical logistic regression.
United States, 1989-1999.
Hospitalized Medicare fee-for-service decedents (n = 976,220) and survivors (n = 845,306) aged 65 years or older.
Admission to the ICU and use of one or more intensive procedures over 12 months, and, for inpatient decedents, during the terminal admission. Black decedents with one or more hospitalization in the last 12 months of life were slightly more likely than non-blacks to be admitted to the ICU during the last 12 months (49.3% vs. 47.4%, p <.0001) and the terminal hospitalization (41.9% vs. 40.6%, p < 0.0001), but these differences disappeared or attenuated in multivariable hierarchical logistic regressions (last 12 months adjusted odds ratio (AOR) 1.0 [0.99-1.03], p = .36; terminal hospitalization AOR 1.03 [1.0-1.06], p = .01). Black decedents were more likely to undergo an intensive procedure during the last 12 months (49.6% vs. 42.8%, p < .0001) and the terminal hospitalization (37.7% vs, 31.1%, p < .0001), a difference that persisted with adjustment (last 12 months AOR 1.1 [1.08-1.14], p < .0001; terminal hospitalization AOR 1.23 [1.20-1.26], p < .0001). Patterns of differences in inpatient treatment intensity by race were reversed among survivors: blacks had lower rates of ICU admission (31.2% vs. 32.4%, p < .0001; AOR 0.93 [0.91-0.95], p < .0001) and intensive procedure use (36.6% vs. 44.2%; AOR 0.72 [0.70-0.73], p <.0001). These differences were driven by greater use by blacks of life-sustaining treatments that predominate among decedents but lesser use of cardiovascular and orthopedic procedures that predominate among survivors. A hospital's black census was a strong predictor of inpatient end-of-life treatment intensity.
Black decedents were treated more intensively during hospitalization than non-black decedents, whereas black survivors were treated less intensively. These differences are strongly associated with a hospital's black census. The causes and consequences of these hospital-level differences in intensity deserve further study.
通过比较医疗保险参保者中幸存者的使用情况，研究种族因素对住院重症监护病房（ICU）及强化治疗手段使用情况的影响。
采用多变量分层逻辑回归对住院理赔数据进行回顾性观察分析。
美国，1989 - 1999年。
65岁及以上的住院医疗保险按服务收费的逝者（n = 976,220）和幸存者（n = 845,306）。
入住ICU情况、12个月内使用一种或多种强化治疗手段的情况，以及住院逝者临终住院期间的情况。在生命最后12个月内有一次或多次住院治疗的黑人逝者，在最后12个月（49.3%对47.4%，p <.0001）和临终住院期间（41.9%对40.6%，p < 0.0001）入住ICU的可能性略高于非黑人，但在多变量分层逻辑回归分析中，这些差异消失或减弱（最后12个月调整优势比[AOR]为1.0[0.99 - 1.03]，p =.36；临终住院AOR为1.03[1.0 - 1.06]，p =.01）。黑人逝者在最后12个月（49.6%对42.8%，p <.0001）和临终住院期间（37.7%对31.1%，p <.0001）接受强化治疗手段的可能性更高，调整后差异依然存在（最后12个月AOR为1.1[1.08 - 1.14]，p <.0001；临终住院AOR为1.23[1.20 - 1.26]，p <.0001）。种族因素导致的住院治疗强度差异模式在幸存者中相反：黑人入住ICU的比例较低（31.2%对32.4%，p <.0001；AOR为0.93[0.91 - 0.95]，p <.0001），使用强化治疗手段的比例也较低（36.6%对44.2%；AOR为0.72[0.70 - 0.73]，p <.0001）。这些差异是由于黑人在逝者中更多地使用维持生命的治疗手段，但在幸存者中较少使用在幸存者中占主导的心血管和骨科治疗手段。医院的黑人患者比例是住院临终治疗强度的有力预测指标。
黑人逝者在住院期间接受的治疗比非黑人逝者更强化，而黑人幸存者接受的治疗则没那么强化。这些差异与医院的黑人患者比例密切相关。这些医院层面治疗强度差异的原因和后果值得进一步研究。
