Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA.
Crit Care Med. 2012 Apr;40(4):1143-9. doi: 10.1097/CCM.0b013e318237706b.
To determine whether insurance coverage and race are associated with long-term acute care hospital utilization in critically ill patients requiring mechanical ventilation.
Retrospective cohort study.
Nonfederal Pennsylvania hospital discharges from 2004 to 2006.
Eligible patients were aged 18 yrs or older, of white or black race, and underwent mechanical ventilation in an intensive care unit during their hospital stay.
None.
We used multivariable logistic regression with hospital-level random effects to determine the independent association between discharge to long-term acute care hospital, insurance status, and race after appropriate controls, including a chart-based measure of severity of illness. The primary outcome measure was discharge to long-term acute care hospital. Of 66,233 eligible patients, 84.7% were white and 15.3% were black. More white patients than black patients had commercial insurance (23.4% vs. 14.9%) compared to Medicaid (10.6% vs. 29.7%) or no insurance (1.3% vs. 2.2%). Long-term acute care hospital transfer occurred in 5.0% of patients. On multivariable analysis in patients aged younger than 65 yrs, black patients were significantly less likely to undergo long-term acute care hospital transfer (odds ratio, 0.71; p = .003), as were patients with Medicaid vs. commercial insurance (odds ratio, 0.17; p < .001). Analyzing race and insurance together and accounting for hospital-level effects, patients with Medicaid were still less likely to undergo long-term acute care hospital transfer (odds ratio, 0.18; p < .001), but race effects were no longer present (odds ratio, 1.06; p = .615). No significant race effects were seen in the Medicare-eligible population aged 65 yrs or older (odds ratio for transfer to long-term acute care hospital, 0.93; p = .359).
Differences in long-term acute care hospital utilization after critical illness appear driven by insurance status and hospital-level effects. Racial variation in long-term acute care hospital use is not seen after controlling for insurance status and is not seen in a group with uniform insurance coverage. Differential access to postacute care may be minimized by expanding commercial or Medicare insurance availability and standardizing long-term acute care admission criteria across hospitals.
确定保险覆盖范围和种族是否与需要机械通气的危重症患者的长期急性护理医院的使用相关。
回顾性队列研究。
宾夕法尼亚州非联邦医院 2004 年至 2006 年的出院记录。
符合条件的患者年龄在 18 岁或以上，为白种人或黑种人，在住院期间接受过重症监护病房的机械通气。
无。
我们使用具有医院水平随机效应的多变量逻辑回归来确定出院至长期急性护理医院、保险状况和种族之间的独立关联，在进行适当的控制后，包括基于图表的疾病严重程度测量。主要结局指标为出院至长期急性护理医院。在 66233 名符合条件的患者中，84.7%为白人，15.3%为黑人。与医疗补助（10.6%比 29.7%）或无保险（1.3%比 2.2%）相比，更多的白人患者比黑人患者有商业保险（23.4%比 14.9%）。有 5.0%的患者接受了长期急性护理医院的转移。在年龄小于 65 岁的患者的多变量分析中，黑人患者进行长期急性护理医院转移的可能性明显较低（比值比，0.71；p=0.003），与商业保险相比，医疗补助患者也是如此（比值比，0.17；p<0.001）。同时分析种族和保险，并考虑医院水平的影响，医疗补助患者接受长期急性护理医院转移的可能性仍然较低（比值比，0.18；p<0.001），但种族效应不再存在（比值比，1.06；p=0.615）。在 65 岁或以上的符合医疗保险条件的人群中，没有明显的种族效应（长期急性护理医院转移的比值比，0.93；p=0.359）。
危重病后长期急性护理医院使用的差异似乎是由保险状况和医院水平的影响驱动的。在控制保险状况后，长期急性护理医院使用中的种族差异并不明显，并且在具有统一保险覆盖范围的人群中也不明显。通过扩大商业或医疗保险的可及性并使医院之间的长期急性护理入院标准标准化，可能会最大限度地减少对急性后护理的差异。
