Ulloa Jesus G, Woo Karen, Tseng Chi-Hong, Maggard-Gibbons Melinda, Rigberg David
Robert Wood Johnson Foundation, Clinical Scholars Program, University of California, Los Angeles, Los Angeles, CA; Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA.
Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, CA; Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, CA.
Ann Vasc Surg. 2017 Jul;42:1-10. doi: 10.1016/j.avsg.2016.10.047. Epub 2017 Mar 7.
Uninsured patients may not have access to postacute care facilities that play an important role in clinical recovery, and functional outcomes after vascular surgery. We sought to determine whether discharge disposition is associated with insurance status.
We retrospectively reviewed data from the Vascular Quality Initiative for patients who underwent open abdominal aortic repair, infrainguinal bypass, or suprainguinal bypass (SB) between January 2012 and July 2015. Mixed-effects logistic regression analysis with clustering at the surgeon and facility level was used to calculate 95% confidence intervals for discharge disposition to home, skilled nursing facility (SNF) or rehabilitation (Rehab) facility by payer status (Medicare, Medicaid, Commercial, Military/Veterans Affairs, Non-US Insurance, or Self-pay), with adjustment for patient, operative, and postoperative characteristics.
The study cohort comprised 18,478 procedures (open abdominal aortic repair = 2,817; infrainguinal bypass = 11,572; suprainguinal bypass = 4,089) after we excluded procedures with missing data and in-hospital deaths. Twenty-four percent of the cohort was discharged to an SNF or Rehab site. On univariate analysis, the odds ratio (OR) of discharge home was 4.38 (95% CI: 3.33-5.77) for self-pay as compared to Medicare. On mixed-effects analysis, the adjusted odds of discharge home for self-pay as compared to Medicare remained high (OR = 3.09; 95% CI: 2.23-4.26), after adjustment for age, gender, race/ethnicity, preoperative ambulatory status, number of comorbidities, case urgency, total operative time, presence of a postoperative complication, procedure type, and length of stay. Adjusted odds for discharge to SNF (OR = 0.26; 95% CI: 0.15-0.46) and Rehab (OR = 0.50; 95% CI: 0.35-0.72) were lowest for self-pay status.
Access to postacute care facilities is associated with insurance status. Self-pay (uninsured) patients are less likely to have access to discharge services that may aid clinical recovery, and functional outcomes after major vascular surgery.
未参保患者可能无法获得在临床康复及血管外科手术后功能转归中发挥重要作用的急性后期护理设施。我们试图确定出院处置是否与保险状态相关。
我们回顾性分析了2012年1月至2015年7月期间接受开放性腹主动脉修复术、腹股沟下旁路移植术或腹股沟上旁路移植术（SB）患者的血管质量改进计划数据。采用在外科医生和机构层面进行聚类的混合效应逻辑回归分析，以计算按付款人状态（医疗保险、医疗补助、商业保险、军事/退伍军人事务部、非美国保险或自费）出院回家、入住熟练护理机构（SNF）或康复机构的95%置信区间，并对患者、手术及术后特征进行调整。
在排除数据缺失和院内死亡的手术病例后，研究队列包括18478例手术（开放性腹主动脉修复术 = 2817例；腹股沟下旁路移植术 = 11572例；腹股沟上旁路移植术 = 4089例）。队列中有24%的患者出院时入住SNF或康复机构。单因素分析显示，与医疗保险患者相比，自费患者出院回家的比值比（OR）为4.38（95%CI：3.33 - 5.77）。混合效应分析显示，在调整年龄、性别、种族/民族、术前活动状态、合并症数量、病例紧急程度、总手术时间、术后并发症的存在、手术类型和住院时间后，与医疗保险患者相比，自费患者出院回家的校正比值仍然较高（OR = 3.09；95%CI：2.23 - 4.26）。自费状态下出院至SNF（OR = 0.26；95%CI：0.15 - 0.46）和康复机构（OR = 0.50；95%CI：0.35 - 0.72）的校正比值最低。
获得急性后期护理设施与保险状态相关。自费（未参保）患者获得有助于临床康复及大血管手术后功能转归的出院服务的可能性较小。
