马萨诸塞州医疗改革对心血管护理中种族、民族和社会经济差异的早期结果。
Early results of Massachusetts healthcare reform on racial, ethnic, and socioeconomic disparities in cardiovascular care.
作者信息
Albert Michelle A, Ayanian John Z, Silbaugh Treacy S, Lovett Ann, Resnic Fred, Jacobs Aryana, Normand Sharon-Lise T
机构信息
From the Divisions of Cardiovascular Medicine and Preventive Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA (M.A.A., F.R.); Division of General Medicine, Brigham and Women's Hospital, Boston, MA (J.Z.A.); Department of Health Care Policy, Harvard Medical School, Boston, MA (J.Z.A., A.L., S.T.N.); Lahey Clinic, Lahey, MA (F.R.); Department of Biostatistics, Harvard School of Public Health, Boston, MA (S.T.N.); Institute of Healthcare Policy, University of Michigan, Ann Arbor (J.Z.A.); and Division of Cardiovascular Medicine at Howard University and Howard University Hospital, Washington, DC (A.J.).
出版信息
Circulation. 2014 Jun 17;129(24):2528-38. doi: 10.1161/CIRCULATIONAHA.113.005231. Epub 2014 Apr 11.
BACKGROUND
Insured adults receive invasive cardiovascular procedures more frequently than uninsured adults. We examined the impact of healthcare reform in Massachusetts on use of coronary revascularization procedures and in-hospital and 1-year mortality by race/ethnicity, education, and sex.
METHODS AND RESULTS
Using hospital claims data, we compared differences in coronary revascularization rates (coronary artery bypass grafting or percutaneous coronary intervention) and in-hospital mortality by race/ethnicity, education, and sex among Massachusetts residents aged 21 to 64 years hospitalized with a principal discharge diagnosis of ischemic heart disease before (November 1, 2004, to July 31, 2006) and after (December 1, 2006, to September 30, 2008) reform; 1-year mortality was calculated for those undergoing revascularization. Adjusted logistic regression assessed 24 216 discharges before reform and 20 721 discharges after reform. Blacks had 30% lower odds of receiving coronary revascularization than whites in the prereform period. Compared with whites in the postreform period, blacks (odds ratio=0.73; 95% confidence interval, 0.63-0.84) and Hispanics (odds ratio= 0.84; 95% confidence interval, 0.74-0.97) were less likely and Asians (odds ratio=1.29; 95% confidence interval, 1.01-1.65) were more likely to receive coronary revascularization. Patients living in more educated communities, men, and persons with private insurance were more likely to receive coronary revascularization before and after reform. Compared with the prereform period, the adjusted odds of in-hospital mortality were higher in patients living in less-educated communities in the postreform period. No differences in 1-year mortality by race/ethnicity, education, or sex for revascularized patients were observed before or after reform.
CONCLUSIONS
Reducing insurance barriers to receipt of coronary revascularization procedures has not yet eliminated preexisting demographic and educational disparities in access to these procedures.
背景
参保成年人接受侵入性心血管手术的频率高于未参保成年人。我们研究了马萨诸塞州医疗改革对冠状动脉血运重建手术的使用情况以及按种族/民族、教育程度和性别划分的住院及1年死亡率的影响。
方法与结果
利用医院理赔数据，我们比较了2004年11月1日至2006年7月31日（改革前）以及2006年12月1日至2008年9月30日（改革后）期间，以缺血性心脏病为主诊断出院的21至64岁马萨诸塞州居民中，按种族/民族、教育程度和性别划分的冠状动脉血运重建率（冠状动脉旁路移植术或经皮冠状动脉介入治疗）及住院死亡率的差异；对接受血运重建的患者计算1年死亡率。调整后的逻辑回归分析评估了改革前的24216例出院病例和改革后的20721例出院病例。在改革前时期，黑人接受冠状动脉血运重建的几率比白人低30%。与改革后时期的白人相比，黑人（比值比=0.73；95%置信区间，0.63 - 0.84）和西班牙裔（比值比=0.84；95%置信区间，0.74 - 0.97）接受冠状动脉血运重建的可能性较小，而亚洲人（比值比=1.29；95%置信区间，1.01 - 1.65）接受冠状动脉血运重建的可能性较大。居住在教育程度较高社区的患者、男性以及有私人保险的患者在改革前后接受冠状动脉血运重建的可能性更大。与改革前时期相比，改革后时期居住在教育程度较低社区的患者住院死亡率调整后的几率更高。在改革前后，接受血运重建的患者按种族/民族、教育程度或性别划分的1年死亡率均未观察到差异。
结论
减少接受冠状动脉血运重建手术的保险障碍尚未消除在获取这些手术方面先前存在的人口统计学和教育程度差异。
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