University of California, San Francisco, Fresno, California.
Saint Luke's Mid-America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri.
JACC Cardiovasc Interv. 2017 Aug 14;10(15):1475-1485. doi: 10.1016/j.jcin.2017.05.042.
This study compared risk-adjusted percutaneous coronary intervention (PCI) outcomes of safety-net hospitals (SNHs) and non-SNHs.
Although risk adjustment is used to compare hospitals, SNHs treat a disproportionate share of uninsured and underinsured patients, who may have unmeasured risk factors, limited health care access, and poorer outcomes than patients treated at non-SNHs.
Using the National Cardiovascular Data Registry CathPCI Registry from 2009 to 2015, we analyzed 3,746,961 patients who underwent PCI at 282 SNHs (hospitals where ≥10% of PCI patients were uninsured) and 1,134 non-SNHs. The relationship between SNH status and risk-adjusted outcomes was assessed.
SNHs were more likely to be lower volume, rural hospitals located in the southern states. Patients treated at SNHs were younger (63 vs. 65 years), more often nonwhite (17% vs. 12%), smokers (33% vs. 26%), and more likely to be admitted through the emergency department (48% vs. 38%) and to have an ST-segment elevation myocardial infarction (20% vs. 14%) than non-SNHs (all p < 0.001). Patients undergoing PCI at SNHs had higher risk-adjusted in-hospital mortality (odds ratio: 1.23; 95% confidence interval: 1.17 to 1.32; p < 0.001), although the absolute risk difference between groups was small (0.4%). Risk-adjusted bleeding (odds ratio: 1.05; 95% confidence interval: 1.00 to 1.12; p = 0.062) and acute kidney injury rates (odds ratio: 1.01; 95% confidence interval: 0.96 to 1.07; p = 0.51) were similar.
Despite treating a higher proportion of uninsured patients with more acute presentations, risk-adjusted PCI-related in-hospital mortality of SNHs is only marginally higher (4 additional deaths per 1,000 PCI cases) than non-SNHs, whereas risk-adjusted bleeding and acute kidney injury rates are comparable.
本研究比较了安全网医院（SNH）和非 SNH 的经皮冠状动脉介入治疗（PCI）风险调整结局。
尽管风险调整用于比较医院，但 SNH 治疗的无保险和保险不足的患者比例不成比例，这些患者可能存在未测量的风险因素、有限的医疗保健机会和比非 SNH 治疗的患者更差的结局。
使用 2009 年至 2015 年国家心血管数据登记处 CathPCI 登记处，我们分析了在 282 家 SNH（接受 PCI 的患者中≥10%无保险）和 1134 家非 SNH 接受 PCI 的 3746961 名患者。评估 SNH 状态与风险调整结局之间的关系。
SNH 更可能是较低容量、位于南部各州的农村医院。在 SNH 接受治疗的患者年龄更小（63 岁 vs. 65 岁），非白人（17% vs. 12%）、吸烟者（33% vs. 26%）的比例更高，更有可能通过急诊就诊（48% vs. 38%），且更有可能患有 ST 段抬高型心肌梗死（20% vs. 14%），而非 SNH（所有 p<0.001）。在 SNH 接受 PCI 的患者的风险调整院内死亡率较高（优势比：1.23；95%置信区间：1.17 至 1.32；p<0.001），尽管两组之间的绝对风险差异较小（0.4%）。风险调整后的出血（优势比：1.05；95%置信区间：1.00 至 1.12；p=0.062）和急性肾损伤发生率（优势比：1.01；95%置信区间：0.96 至 1.07；p=0.51）相似。
尽管 SNH 治疗的无保险患者比例更高，且临床表现更急性，但风险调整后的 PCI 相关院内死亡率仅略高于非 SNH（每 1000 例 PCI 病例增加 4 例死亡），而风险调整后的出血和急性肾损伤发生率相似。
