Eskander Mariam F, Bliss Lindsay A, McCarthy Ellen P, de Geus Susanna W L, Chau Ng Sing, Nagle Deborah, Rodrigue James R, Tseng Jennifer F
1 Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 2 Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 3 Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Dis Colon Rectum. 2016 Nov;59(11):1063-1072. doi: 10.1097/DCR.0000000000000697.
Insurance impacts access to therapeutic options, yet little is known about how healthcare reform might change the pattern of surgical admissions.
We compared rates of emergent admissions and outcomes after colectomy before and after reform in Massachusetts with a nationwide control group.
This study is a retrospective cohort analysis in a natural experiment. Prereform was defined as hospital discharge from 2002 through the second quarter of 2006 and postreform from the third quarter of 2006 through 2012. Categorical variables were compared by χ. Piecewise functions were used to test the effect of healthcare reform on the rate of emergent surgeries.
The study included acute care hospitals in the Massachusetts Healthcare Cost and Utilization Project State Inpatient Database (2002-2012) and the Nationwide Inpatient Sample (2002-2011).
Patients aged 18 to 64 years with public or no insurance who underwent inpatient colectomy (via International Classification of Diseases, Ninth Revision, Clinical Modification procedural code) were included and patients with Medicare were excluded.
Massachusetts health care reform was the study intervention.
We measured the rate of emergent colectomy, complications, and mortality.
The unadjusted rate of emergent colectomies was lower in Massachusetts after reform but did not change nationally over the same time period. For emergent surgeries in Massachusetts, a piecewise model with an inflection point (peak) in the third quarter of 2006, coinciding with implementation of healthcare reform in Massachusetts, had a lower mean squared error than a linear model. In comparison, the national rate of emergent surgeries demonstrated no change in pattern. Postreform, length of stay decreased by 1 day in Massachusetts; however, there were no significant improvements in other outcomes.
The study was limited by its retrospective design and unadjusted analysis.
There was a unique and sustained decline in the rate of emergent colon resection among publically insured and uninsured patients after 2006 in Massachusetts, in contradistinction to the national pattern, suggesting improved access to care associated with health insurance expansion. The reasons for lack of improvement in outcomes are multifactorial.
保险会影响治疗选择的可及性，但对于医疗改革如何改变手术入院模式却知之甚少。
我们将马萨诸塞州改革前后结肠切除术后的急诊入院率及结果与全国对照组进行了比较。
本研究是一项自然实验中的回顾性队列分析。改革前定义为2002年至2006年第二季度的出院病例，改革后定义为2006年第三季度至2012年的出院病例。分类变量采用χ检验进行比较。使用分段函数来检验医疗改革对急诊手术率的影响。
该研究纳入了马萨诸塞州医疗成本与利用项目州住院数据库（2002 - 2012年）和全国住院样本（2002 - 2011年）中的急性护理医院。
纳入年龄在18至64岁、有公共保险或无保险且接受住院结肠切除术（通过国际疾病分类第九版临床修正版程序编码）的患者，排除有医疗保险的患者。
马萨诸塞州医疗改革是研究干预措施。
我们测量了急诊结肠切除术的发生率、并发症及死亡率。
改革后马萨诸塞州急诊结肠切除术的未调整发生率较低，但同期全国范围内未发生变化。对于马萨诸塞州的急诊手术，一个在2006年第三季度有拐点（峰值）的分段模型，与马萨诸塞州医疗改革的实施时间相符，其均方误差低于线性模型。相比之下，全国急诊手术率的模式没有变化。改革后，马萨诸塞州的住院时间缩短了1天；然而，其他结局指标没有显著改善。
该研究受其回顾性设计和未调整分析的限制。
2006年后，马萨诸塞州公共保险和无保险患者的急诊结肠切除术发生率出现了独特且持续的下降，这与全国模式不同，表明与医疗保险扩大相关的医疗可及性得到了改善。结局指标缺乏改善的原因是多方面的。
