Neurosurgical Service, Massachusetts General Hospital, and Department of Surgery, Harvard Medical School, Boston, Massachusetts 02114, USA.
Neurosurgery. 2010 Mar;66(3):427-37; discussion 437-8. doi: 10.1227/01.NEU.0000365265.10141.8E.
Racial disparities in American health care outcomes are well documented. We investigated racial disparities in hospital mortality and adverse discharge disposition after brain tumor craniotomies performed in the United States from 1988 to 2004. We explored potential explanations for the disparities.
The data source was the Nationwide Inpatient Sample. We used multivariate ordinal logistic regression corrected for clustering by hospital and adjusted for age, sex, primary payer for care, income in postal code of residence, geographic region, admission type and source, medical comorbidity, treatment year, hospital case volume, and disease-specific factors. Random-effects pooling was also used.
A total of 99 665 craniotomies were studied. Hospital mortality and adverse discharge disposition (any discharge other than directly home) were more likely in black patients than others for all tumor types. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) for blacks were: hospital craniotomy mortality (OR, 1.64; 95% CI, 1.32-2.03; P < .001), and adverse discharge disposition (OR, 1.43; 95% CI, 1.31-1.56; P < .001). Medicaid patients had higher mortality, while private-pay patients had lower mortality. Hospital annual case volume was lower for black and Hispanic patients and for those with Medicaid as the primary payer in pooled analyses, whereas patients with private insurance received care at higher-volume hospitals. Black patients generally presented with higher disease severity, including more emergency or urgent admissions (OR, 1.71; 95% CI, 1.54-1.89; P < .001); more hemiparesis and hemiplegia for primary tumors, meningiomas, and metastases (P < .04 for all); and more hydrocephalus for acoustic neuromas (P = .1).
Black patients died more often or had an adverse discharge disposition after tumor craniotomies in the United States in the period studied (1988-2004). Blacks had more severe disease at presentation and were treated at lower-volume hospitals for surgery. Other socially defined patient groups also showed disparities in access and outcomes of care.
美国医疗保健结果的种族差异有充分的记录。我们研究了 1988 年至 2004 年期间在美国进行的脑肿瘤开颅手术后医院死亡率和不良出院处置的种族差异。我们探讨了差异的潜在解释。
数据源是全国住院患者样本。我们使用多元有序逻辑回归校正了医院聚类，并调整了年龄、性别、医疗保健的主要支付方、居住地邮政编码的收入、地理区域、入院类型和来源、合并症、治疗年份、医院病例量以及疾病特异性因素。还使用了随机效应汇总。
共研究了 99665 例开颅手术。对于所有肿瘤类型，黑人患者的医院死亡率和不良出院处置（任何非直接出院的情况）的可能性均高于其他患者。黑人的汇总优势比（OR）和 95%置信区间（CI）为：医院开颅术死亡率（OR，1.64；95%CI，1.32-2.03；P<0.001）和不良出院处置（OR，1.43；95%CI，1.31-1.56；P<0.001）。医疗补助患者的死亡率较高，而私人支付患者的死亡率较低。在汇总分析中，黑人患者和西班牙裔患者以及医疗补助为主要支付方的患者的医院年度病例量较低，而私人保险患者在高容量医院接受治疗。黑人患者通常表现出更高的疾病严重程度，包括更多的紧急或紧急入院（OR，1.71；95%CI，1.54-1.89；P<0.001）；原发性肿瘤、脑膜瘤和转移瘤的偏瘫和偏瘫（所有肿瘤均为 P<0.04）；以及听神经瘤的脑积水（P=0.1）。
在研究期间（1988-2004 年），美国黑人患者在脑肿瘤开颅手术后死亡或出院不良的情况更为常见。黑人患者在就诊时病情更严重，手术时在容量较低的医院接受治疗。其他社会定义的患者群体在获得医疗服务和治疗结果方面也存在差异。
