Nallamothu Brahmajee K, Lu Xin, Vaughan-Sarrazin Mary S, Cram Peter
Health Services Research and Development Center of Excellence, Ann Arbor VA Medical Center, Ann Arbor, Mich, USA.
Circ Cardiovasc Qual Outcomes. 2008 Nov;1(2):116-22. doi: 10.1161/CIRCOUTCOMES.108.800086. Epub 2008 Nov 5.
Critics have raised concerns that specialty cardiac hospitals exacerbate racial disparities in cardiovascular care, but empirical data are limited.
We used administrative data from the Medicare Provider and Analysis Review Part A and Provider-of-Service files from 2002 to 2005. Multivariable logistic regression models were constructed to examine the likelihood of black Medicare patients being admitted to a cardiac hospital for coronary revascularization when compared with white patients within the same healthcare referral region after accounting for geographic proximity to the nearest hospitals, procedural acuity, and comorbidities. We identified 35 309 patients who underwent coronary artery bypass grafting in 18 healthcare referral regions and 94,525 patients who underwent percutaneous coronary intervention in 20 healthcare referral regions where cardiac hospitals performed these procedures. Patients at cardiac hospitals were more likely to be men and white and have less comorbidity than those at general hospitals. The likelihood of black patients undergoing coronary revascularization at a cardiac hospital was significantly lower for coronary artery bypass grafting (adjusted odds ratio, 0.67; P=0.01) and percutaneous coronary intervention (adjusted odds ratio, 0.63; P<0.0001). However, this relationship was substantially attenuated among black patients living in close proximity (ie, within 10 miles) to cardiac hospitals (adjusted odds ratio for coronary artery bypass grafting, 0.95; P=0.75; adjusted odds ratio for percutaneous coronary intervention, 0.78; P=0.01).
Black patients were significantly less likely to be admitted at cardiac hospitals for coronary revascularization. Precise reasons for these findings are unclear but suggest complex associations between race and geography in decisions about where to receive care.
批评者担心专科心脏病医院会加剧心血管护理方面的种族差异，但实证数据有限。
我们使用了2002年至2005年医疗保险提供者分析与审查A部分的管理数据以及服务提供者文件。构建多变量逻辑回归模型，以检验在考虑到与最近医院的地理距离、手术急症程度和合并症的情况下，与同一医疗转诊区域内的白人患者相比，黑人医疗保险患者因冠状动脉血运重建而入住心脏病医院的可能性。我们在18个医疗转诊区域中确定了35309例接受冠状动脉搭桥术的患者，在20个有心脏病医院进行这些手术的医疗转诊区域中确定了94525例接受经皮冠状动脉介入治疗的患者。与综合医院的患者相比，心脏病医院的患者更可能为男性和白人，且合并症较少。在心脏病医院接受冠状动脉血运重建的黑人患者，冠状动脉搭桥术的可能性显著较低（调整后的优势比为0.67；P=0.01），经皮冠状动脉介入治疗的可能性也显著较低（调整后的优势比为0.63；P<0.0001）。然而，对于居住在距离心脏病医院较近（即10英里以内）的黑人患者，这种关系显著减弱（冠状动脉搭桥术的调整后优势比为0.95；P=0.75；经皮冠状动脉介入治疗的调整后优势比为0.78；P=0.01）。
黑人患者因冠状动脉血运重建而入住心脏病医院的可能性显著较低。这些发现的确切原因尚不清楚，但表明在就医地点决策中种族与地理位置之间存在复杂关联。
