Department of Urology, University of Washington, Seattle, Washington.
Department of Urology, University of California San Francisco, San Francisco, California.
Cancer. 2018 Aug;124(16):3372-3380. doi: 10.1002/cncr.31587. Epub 2018 Jun 15.
Safety-net hospitals (SNHs) care for more patients of low socioeconomic status (SES) than non-SNHs and are disproportionately punished under SES-naive Medicare readmission risk-adjustment models. This study was designed to develop a risk-adjustment framework that incorporates SES and to assess the impact on readmission rates.
California Office of Statewide Health Planning and Development data from 2007 to 2011 were used to identify patients undergoing radical cystectomy (RC) for bladder cancer (n = 3771) or partial nephrectomy (PN; n = 5556) or radical nephrectomy (RN; n = 13,136) for kidney cancer. Unadjusted hospital rankings and predicted rankings under models simulating the Medicare Hospital Readmissions Reduction Program were compared with predicted rankings under models incorporating SES and hospital factors. SES, derived from a multifactorial neighborhood score, was calculated from US Census data.
The 30-day readmission rate was 26.1% for RC, 8.3% for RN, and 9.5% for PN. The addition of SES, geographic, and hospital factors changed hospital rankings significantly in comparison with the base model (P < .01) except for SES for RC (P = .07) and SES and rural factors for PN (P = .12). For RN and PN, the addition of SES predicted lower percentile ranks for SNHs and thus improved observed-to-expected rankings (P < .01). For RC, there were no changes in hospital rankings.
SES is important for risk adjustments for complex surgical procedures such as RC. Patient SES affects overall hospital rankings across cohorts, and critically, it differentially and punitively affects rankings for SNHs for some procedures. Cancer 2018. © 2018 American Cancer Society.
相比于非安全网医院（SNH），安全网医院（SNH）为更多社会经济地位（SES）较低的患者提供服务，且在 SES 无知觉的医疗保险再入院风险调整模型下被不成比例地惩罚。本研究旨在开发一种包含 SES 的风险调整框架，并评估其对再入院率的影响。
利用 2007 年至 2011 年加利福尼亚州全州卫生规划和发展办公室的数据，确定接受膀胱癌根治性切除术（RC）治疗（n=3771）、部分肾切除术（PN；n=5556）或肾癌根治性肾切除术（RN；n=13136）的患者。比较未调整的医院排名和模拟医疗保险医院再入院减少计划的模型下的预测排名，以及纳入 SES 和医院因素的模型下的预测排名。SES 来源于一个多因素邻里评分，由美国人口普查数据计算得出。
RC 的 30 天再入院率为 26.1%，RN 的为 8.3%，PN 的为 9.5%。与基础模型相比（P<.01），SES、地理和医院因素的增加显著改变了医院排名，除了 RC 的 SES（P=.07）和 PN 的 SES 和农村因素（P=.12）之外。对于 RN 和 PN，SES 的增加预测了 SNH 的较低百分位排名，从而改善了观察到的与预期的排名（P<.01）。对于 RC，医院排名没有变化。
SES 对于 RC 等复杂手术的风险调整很重要。患者 SES 影响整个队列的医院总体排名，而且重要的是，它对某些手术的 SNH 排名产生不同且惩罚性的影响。癌症 2018。© 2018 美国癌症协会。
