Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio.
Sg2 Health Care and Hospital System Consultancy, Chicago, Illinois.
JAMA Surg. 2016 Feb;151(2):120-8. doi: 10.1001/jamasurg.2015.3209.
Safety-net hospitals provide broad services for a vulnerable population of patients and are financially at risk owing to impending reimbursement penalties and policy changes.
To determine the effect of patient and hospital factors on surgical outcomes and cost at safety-net hospitals.
DESIGN, SETTING, AND PARTICIPANTS: Hospitals in the University HealthSystem Consortium database from January 1, 2009, through December 31, 2012 (n = 31), were grouped according to their safety-net burden, defined as the proportion of Medicaid and uninsured patient charges for all hospitalizations during that time (n = 12,638,166). Nine cohorts, based on a variety of surgical procedures, were created and examined with regard to preoperative characteristics, postoperative outcomes, and resource utilization. Multiple logistic regression was performed to analyze the effect of patient and center factors on outcomes. Hospital Compare data from the Centers for Medicare & Medicaid Services were linked and used to characterize and compare the groups of hospitals.
Postoperative mortality, 30-day readmissions, and total direct cost.
For all 9 procedures examined in 231 hospitals comprising 12,638,166 patient encounters, patients at hospitals with high safety-net burden (HBHs) (vs hospitals with low and medium safety-net burdens) were most likely to be young, to be black, to be of the lowest socioeconomic status, and to have the highest severity of illness and the highest cost for surgical care (P < .01 for all). For 7 of 9 procedures, HBHs had the highest proportion of emergent cases and longest length of stay (P < .01 for all). After adjusting for patient characteristics and center volume, HBHs still had higher odds of mortality for 3 procedures (odds ratios [ORs], 1.81-2.08; P < .05), readmission for 2 procedures (ORs, 1.19-1.30; P < .05), and the highest cost of care associated with 7 of 9 procedures (risk ratios, 1.23-1.35; P < .05). Analysis of Hospital Compare data found that HBHs had inferior performance on Surgical Care Improvement Project measures, higher rates of surgical complications, and inferior markers of emergency department timeliness and efficiency (all P < .05).
These data suggest that intrinsic qualities of safety-net hospitals lead to inferior surgical outcomes and increased cost across 9 elective surgical procedures. These outcomes are likely owing to hospital resources and not necessarily patient factors. In addition, impending changes to reimbursement may have a negative effect on the surgical care at these centers.
提供广泛服务给弱势病患群体的安全网医院由于即将面临的报销罚款和政策变化而面临财务风险。
确定患者和医院因素对安全网医院外科手术结果和成本的影响。
设计、地点和参与者： 2009 年 1 月 1 日至 2012 年 12 月 31 日期间，根据其安全网负担程度，将大学卫生系统联合数据库中的医院（n=31）分为 9 组，安全网负担程度定义为同期所有住院治疗中医疗补助和无保险患者费用的比例（n=12,638,166）。根据各种手术程序创建了九个队列，并检查了术前特征、术后结果和资源利用情况。采用多变量逻辑回归分析患者和中心因素对结果的影响。医疗保险和医疗补助服务中心的医院比较数据被链接并用于描述和比较各组医院。
术后死亡率、30 天再入院率和总直接成本。
在涉及 231 家医院的 12,638,166 例患者中，对所有 9 种手术进行检查，高安全网负担（HBH）医院（与低和中安全网负担医院相比）的患者最有可能年轻、是黑人、社会经济地位最低、手术治疗的疾病严重程度和费用最高（所有 P<0.01）。对于 9 种手术中的 7 种，HBH 中紧急情况的比例最高，住院时间最长（所有 P<0.01）。在调整患者特征和中心数量后，HBH 对 3 种手术的死亡率仍然较高（优势比[OR]，1.81-2.08；P<0.05），2 种手术的再入院率（OR，1.19-1.30；P<0.05），以及 7 种手术中与护理成本最高相关的风险比（1.23-1.35；P<0.05）。对医院比较数据的分析发现，HBH 在外科手术改进项目措施方面表现不佳，手术并发症发生率更高，急诊科及时性和效率指标更差（所有 P<0.05）。
这些数据表明，安全网医院的内在特质导致 9 种择期手术的手术结果较差和成本增加。这些结果可能是由于医院资源造成的，而不一定是患者因素。此外，即将发生的报销变化可能对这些中心的外科护理产生负面影响。
