马萨诸塞州的改革与住院医疗利用的差异。
Massachusetts reform and disparities in inpatient care utilization.
机构信息
VA Boston Healthcare System, USA.
出版信息
Med Care. 2012 Jul;50(7):569-77. doi: 10.1097/MLR.0b013e31824e319f.
BACKGROUND
The 2006 Massachusetts health reform substantially decreased uninsurance rates. Yet, little is known about the reform's impact on actual health care utilization among poor and minority populations, particularly for receipt of inpatient surgical procedures that are commonly initiated by outpatient physician referral.
METHODS
Using discharge data on Massachusetts hospitalizations for 21 months before and after health reform implementation (7/1/2006-12/31/2007), we identified all nonobstetrical major therapeutic procedures for patients aged 40 or older and for which ≥70% of hospitalizations were initiated by outpatient physician referral. Stratifying by race/ethnicity and patient residential zip code median (area) income, we estimated prereform and postreform procedure rates, and their changes, for those aged 40-64 (nonelderly), adjusting for secular changes unrelated to reform by comparing to corresponding procedure rate changes for those aged 70 years and above (elderly), whose coverage (Medicare) was not affected by reform.
RESULTS
Overall increases in procedure rates (among 17 procedures identified) between prereform and postreform periods were higher for nonelderly low area income (8%, P=0.04) and medium area income (8%, P<0.001) cohorts than for the high area income cohort (4%); and for Hispanics and blacks (23% and 21%, respectively; P<0.001) than for whites (7%). Adjusting for secular changes unrelated to reform, postreform increases in procedure utilization among nonelderly were: by area income, low=13% (95% confidence interval (CI)=[9%, 17%]), medium=15% (95% CI [6%, 24%]), and high=2% (95% CI [-3%, 8%]); and by race/ethnicity, Hispanics=22% (95% CI [5%, 38%]), blacks=5% (95% CI [-20%, 30%]), and whites=7% (95% CI [5%, 10%]).
CONCLUSIONS
Postreform use of major inpatient procedures increased more among nonelderly lower and medium area income populations, Hispanics, and whites, suggesting potential improvements in access to outpatient care for these vulnerable subpopulations.
背景
2006 年马萨诸塞州的医疗改革大幅降低了未参保率。然而，对于改革对贫困和少数族裔人群实际医疗利用的影响，尤其是对于常见的门诊医生转介发起的住院手术的接受情况，人们知之甚少。
方法
利用改革实施前后 21 个月的马萨诸塞州住院治疗出院数据（2006 年 7 月 1 日至 2007 年 12 月 31 日），我们确定了所有年龄在 40 岁或以上的非产科主要治疗性手术，并且 70%以上的住院治疗是由门诊医生转介发起的。按照种族/民族和患者居住邮编中位数（地区）收入进行分层，我们估算了 40-64 岁（非老年人）的改革前和改革后的手术率，并对其进行了调整，以反映与改革无关的长期变化，方法是将其与 70 岁及以上（老年人）的相应手术率变化进行比较，因为他们的保险（医疗保险）不受改革影响。
结果
在确定的 17 项手术中，非老年人低地区收入（8%，P=0.04）和中等地区收入（8%，P<0.001）队列与高地区收入队列（4%）相比，在改革前后期间手术率的总体上升幅度更高；与白人（7%）相比，西班牙裔和黑人（分别为 23%和 21%）更高。调整与改革无关的长期变化后，非老年人在改革后的手术利用率增加：按地区收入，低=13%（95%置信区间（CI）=[9%，17%]），中=15%（95% CI [6%，24%]），高=2%（95% CI [-3%，8%]）；按种族/民族，西班牙裔=22%（95% CI [5%，38%]），黑人=5%（95% CI [-20%，30%]），白人=7%（95% CI [5%，10%]）。
结论
改革后，较低和中等地区收入人群、西班牙裔和白人等非老年人的主要住院手术使用量增加更多，这表明这些弱势群体获得门诊护理的机会可能有所改善。
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