Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
J Surg Res. 2020 Feb;246:123-130. doi: 10.1016/j.jss.2019.09.003. Epub 2019 Sep 27.
National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures.
We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent.
We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09).
Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized.
在创伤护理环境中，医疗保健差距方面的国家变化尚未在问责制医疗保健组织（ACO）或非 ACO 中进行检查。我们试图研究 ACO 对白人及非白人脊柱骨折患者的治疗后结果（住院死亡率、90 天并发症和再入院率）以及手术干预的影响。
我们使用全国医疗保险按服务收费数据，确定了 2009 年至 2014 年间所有接受脊柱骨折治疗的受益人的数据。这些索赔被用来确定社会人口统计学和临床标准、手术和住院死亡率、90 天并发症和再入院率。使用多变量逻辑回归分析，考虑到所有混杂因素，确定种族/民族对结果的影响。2009 年至 2011 年，非白人患者在非 ACO 中接受治疗时被视为白人患者的参照组。
我们确定了 245704 名接受脊柱骨折治疗的患者。该队列中有 2%的患者在 ACO 接受治疗，而 7%是非白人。我们发现，在 2009 年至 2014 年期间，非 ACO 中脊柱骨折手术固定的使用存在差异，但在 ACO 提供的护理中不存在差异（比值比 [OR]0.75；95%置信区间 [CI]0.44，1.28）。非 ACO 中，非白人患者的并发症发生率存在差异（OR1.09；95%CI1.01，1.17），而在 ACO 中接受治疗的非白人患者则没有这种差异（OR1.32；95%CI0.90，1.95）。2009 年至 2011 年期间，ACO 中非白人患者的再入院率存在差异（OR1.34；95%CI1.01，1.80），但在 2012 年至 2014 年期间，这一差异消除了（OR0.85；95%CI0.65，1.09）。
我们的工作强化了 ACO 可以改善非白人的医疗保健差距这一观点。随着 ACO 越来越熟悉医疗服务的整合和简化，在减少差距方面可能会有进一步的改善。
