Won Roy P, Friedlander Scott, Lee Steven L
Department of Surgery, Harbor-University of California Los Angeles Medical Center, Torrance, California.
Los Angeles Biomedical Research Institute, Torrance, California.
JAMA Surg. 2017 Nov 1;152(11):1001-1006. doi: 10.1001/jamasurg.2017.2209.
Safety-net hospitals serve vulnerable populations with limited resources. Although complex, elective operations performed at safety-net hospitals have been associated with inferior outcomes and higher costs, it is unclear whether a similar association has been seen with common emergency general surgery performed at safety-net hospitals.
To evaluate the association of safety-net burden with the outcomes of appendectomy.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective review was conducted of all nonfederally funded hospitals in the California state inpatient database that performed appendectomies from January 1, 2005, to December 31, 2011. A total of 349 hospitals performing 274 405 nonincidental appendectomies were stratified based on safety-net burden; low-burden hospitals had the lowest quartile of patients who either had Medicaid or were uninsured (0%-14%), medium-burden hospitals had the middle 2 quartiles (15%-41%), and high-burden hospitals had the highest quartile (>42%). Data analysis was performed from August 27 to September 8, 2016.
Rates of laparoscopy, perforation, negative appendectomy, morbidity, length of stay, and cost.
Among the 349 hospitals in the study, high-burden hospitals treated a larger proportion of black patients than did medium- and low-burden hospitals (4.5% vs 2.4% vs 2.9%; P = .01), as well as Hispanic patients (64.8% vs 27.0% vs 22.0%; P < .001) and patients with perforated appendicitis (27.6% vs 23.6% vs 23.6%; P = .005). High-burden hospitals were less likely than medium- or low-burden hospitals to use laparoscopy (51.6% vs 60.7% vs 71.9%; P < .001). There were no differences in morbidity, length of stay, or cost. Multivariable regression analysis confirmed that high-burden hospitals were more likely than low-burden hospitals to treat perforated appendicitis (log %, 0.07; 95% CI, 0.03-0.12; P = .04) and less likely to use laparoscopy (-16.9% difference; 95% CI, -26.1% to -7.6%; P < .001), while achieving similar complication rates. Multivariable analysis also confirmed that high-burden hospitals have similar costs, despite being associated with longer length of stay (relative risk, 1.17; 95% CI, 1.09-1.26; P < .001).
Safety-net hospitals treat a disproportionate number of patients with advanced appendicitis while falling behind in the use of laparoscopy. Nonetheless, safety-net hospitals treat this common surgical emergency with morbidity and cost similar to that seen at other hospitals. Additional research is needed to evaluate how these outcomes are achieved to improve all surgical outcomes at underresourced hospitals.
安全网医院为资源有限的弱势群体提供服务。尽管在安全网医院进行的复杂择期手术与较差的预后和更高的成本相关，但尚不清楚在安全网医院进行的常见急诊普通外科手术是否也存在类似关联。
评估安全网负担与阑尾切除术预后之间的关联。
设计、设置和参与者：对加利福尼亚州住院患者数据库中2005年1月1日至2011年12月31日期间进行阑尾切除术的所有非联邦资助医院进行回顾性研究。共有349家医院进行了274405例非偶然阑尾切除术，根据安全网负担进行分层；低负担医院的医疗补助患者或未参保患者比例处于最低四分位数（0%-14%），中等负担医院的该比例处于中间两个四分位数（15%-41%），高负担医院的该比例处于最高四分位数（>42%）。数据分析于2016年8月27日至9月8日进行。
腹腔镜手术率、穿孔率、阴性阑尾切除术率（阴性切除率）、发病率、住院时间和费用。
在研究的349家医院中，高负担医院治疗的黑人患者比例高于中等和低负担医院（4.5%对2.4%对2.9%；P = 0.01），西班牙裔患者比例也更高（64.8%对27.０%对22.0%；P < 0.001），穿孔性阑尾炎患者比例同样更高（27.6%对23.6%对23.6%；P = 0.005）。高负担医院使用腹腔镜的可能性低于中等或低负担医院（51.6%对60.7%对71.9%；P < 0.001）。在发病率、住院时间或费用方面没有差异。多变量回归分析证实，高负担医院比低负担医院更有可能治疗穿孔性阑尾炎（对数百分比，0.07；95%置信区间，0.03 - 0.12；P = 0.04），使用腹腔镜的可能性更低（差异为-16.9%；95%置信区间，-26.1%至-7.6%；P < 0.001），同时并发症发生率相似。多变量分析还证实，高负担医院的费用相似，尽管住院时间更长（相对风险，1.17；95%置信区间，1.09 - 1.26；P < 0.001）。
安全网医院治疗的晚期阑尾炎患者数量不成比例，同时在腹腔镜使用方面落后。尽管如此，安全网医院治疗这种常见外科急诊的发病率和成本与其他医院相似。需要进一步研究以评估如何实现这些结果，从而改善资源不足医院的所有外科手术预后。
