Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA; Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA; Division of Cardiology, Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, CA.
Surgery. 2019 Nov;166(5):778-784. doi: 10.1016/j.surg.2019.05.034. Epub 2019 Jul 12.
Hospitals with safety-net status have been associated with inferior surgical outcomes and higher costs. The mechanism of this discrepancy, however, is not well understood. We hypothesized that discrepant rates of failure to rescue after complications of routine cardiac surgery would explain the observed inferior outcomes at safety-net hospitals.
The National Inpatient Sample was used to identify adult patients who underwent elective coronary artery bypass grafting and isolated or concomitant valve operations between January 2005 and December 2016. Hospitals were stratified into low-, medium-, or high-burden categories based on the proportion of uninsured or Medicaid patients to emulate safety-net status as defined by the Institute of Medicine. Failure to rescue was defined as mortality after occurrence of neurologic, cardiovascular, respiratory, renal, or infectious complications (major and minor complications). Multivariable regression was used to perform risk-adjusted comparisons of the rate of complications, failures to rescue, and resource use for high-burden hospitals versus low-burden and medium-burden hospitals.
Of an estimated 2,012,104 patients undergoing elective major cardiac operations, 2% died, whereas 36% suffered major and minor complications. Safety-net hospitals had higher odds of failure to rescue after major comorbidity (adjusted odds ratio 1.12, 95% confidence interval 1.01-1.23). Occurrence of major and minor complications at safety-net hospitals was associated with increased costs ($2,480 [95% confidence interval $1,178-$3,935]) compared with low-burden hospitals.
Safety-net hospitals were associated with higher rates of failure to rescue after occurrence of tamponade, septicemia, and respiratory complications. Implementation of care bundles to tackle cardiovascular, respiratory, and renal complications may affect the discrepancy in incidence of and rescue from complications at safety-net institutions.
具有安全网状态的医院与较差的手术结果和较高的成本相关。然而，这种差异的机制尚不清楚。我们假设，在常规心脏手术后并发症的抢救失败率的差异可以解释在安全网医院观察到的较差结果。
利用国家住院患者样本，确定 2005 年 1 月至 2016 年 12 月期间接受择期冠状动脉旁路移植术和单独或同时瓣膜手术的成年患者。根据无保险或医疗补助患者的比例，将医院分为低、中或高负担类别，以模拟医学研究所定义的安全网状态。抢救失败定义为发生神经、心血管、呼吸、肾脏或感染并发症（主要和次要并发症）后的死亡率。多变量回归用于对高负担医院与低负担和中负担医院的并发症、抢救失败率和资源使用进行风险调整比较。
在估计的 2012104 例择期主要心脏手术患者中，2%死亡，36%发生主要和次要并发症。安全网医院在发生主要合并症后抢救失败的可能性更高（调整后的优势比 1.12，95%置信区间 1.01-1.23）。与低负担医院相比，安全网医院发生主要和次要并发症与增加的成本相关（$2480[95%置信区间$1178-$3935]）。
安全网医院与填塞、败血症和呼吸并发症发生后抢救失败的比率较高相关。实施针对心血管、呼吸和肾脏并发症的护理包可能会影响安全网机构并发症的发生率和抢救差异。
