Eslami Mohammad H, Rybin Denis, Doros Gheorghe, Farber Alik
Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass.
Department of Biostatistics, Boston University School of Public Health, Boston, Mass.
J Vasc Surg. 2014 Dec;60(6):1627-34. doi: 10.1016/j.jvs.2014.08.055. Epub 2014 Oct 14.
This study compared in-hospital mortality and resource utilization among vascular surgical patients at safety net public hospitals (SNPHs) with those at nonsafety net public hospitals (nSNPHs).
The National Inpatient Sample (2003-2011) was queried to identify surgical patients with peripheral arterial disease (PAD), carotid stenosis, or nonruptured abdominal aorta aneurysm based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedure codes. The cohort was then divided into SNPH and nSNPH groups according to the definition of SNPH used by the National Association of Public Hospitals. Clinical characteristics, length of stay, in-hospital mortality, and hospital charges were compared between groups. Advanced PAD was defined as that associated with rest pain or tissue loss. Statistical methods included bivariate χ(2) tests for categoric variables, t-tests for continuous variables, and multivariable linear and logistic regression to adjust for confounding variables (in-hospital mortality).
We identified 306,438 patients operated on for PAD, carotid stenosis, and abdominal aortic aneurysm. Patients at SNPHs were younger, the percentage of female and minority patients was higher, and patients had a higher Elixhauser comorbidity index (P < .001). Nonelective admissions were more common among SNPH patients who presented with more advanced PAD (P > .05) and symptomatic carotid stenosis (P < .05). Patients at SNPHs had a significantly longer length of stay, higher hospital charges, and higher in-hospital mortality (P < .05 for all variables). Crude odds of mortality at SNPHs were 1.28 higher than at nSNPHs (95% confidence interval, 1.13-1.46; P < .001), but adjusted analyses revealed no statistically significant difference between the odds of in-hospital mortality at both hospital groups.
Patients undergoing vascular surgery at SNPHs, despite being younger, had higher comorbidities, presented more urgently with more advanced disease, and incurred higher costs than the SNPH cohort despite similar adjusted odds of in-hospital mortality. Delayed presentation and higher comorbidities are most likely related to poor access to routine and preventive health care for the SNPH patients.
本研究比较了安全网公立医院（SNPHs）与非安全网公立医院（nSNPHs）血管外科患者的院内死亡率和资源利用情况。
查询国家住院患者样本（2003 - 2011年），根据国际疾病分类第九版临床修订本的诊断和手术编码，确定患有外周动脉疾病（PAD）、颈动脉狭窄或未破裂腹主动脉瘤的手术患者。然后根据公立医院协会使用的SNPH定义将该队列分为SNPH组和nSNPH组。比较两组的临床特征、住院时间、院内死亡率和医院费用。晚期PAD定义为与静息痛或组织缺失相关的情况。统计方法包括对分类变量的双变量χ²检验、对连续变量的t检验以及用于调整混杂变量（院内死亡率）的多变量线性和逻辑回归。
我们确定了306438例接受PAD、颈动脉狭窄和腹主动脉瘤手术的患者。SNPHs的患者更年轻，女性和少数族裔患者的比例更高，且患者的埃利克斯豪泽合并症指数更高（P <.001）。非选择性入院在患有更晚期PAD（P >.05）和有症状颈动脉狭窄（P <.05）的SNPH患者中更为常见。SNPHs的患者住院时间显著更长，医院费用更高，院内死亡率也更高（所有变量P <.05）。SNPHs的粗死亡率比nSNPHs高1.28倍（95%置信区间，1.13 - 1.46；P <.001），但调整分析显示两组医院的院内死亡几率在统计学上无显著差异。
在SNPHs接受血管手术的患者尽管更年轻，但合并症更多，疾病更晚期且就诊更紧急，尽管调整后的院内死亡几率相似，但费用却比nSNPH队列更高。就诊延迟和合并症更多很可能与SNPH患者难以获得常规和预防性医疗保健有关。
