比较教学医院和非教学医院 homeless 患者的 30 天再入院率和急诊复诊率。
Comparison of 30-day readmission and emergency department revisit rates among homeless patients at teaching versus non-teaching hospitals.
机构信息
Department of Public Health, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan; Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan.
Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
出版信息
Soc Sci Med. 2020 Oct;263:113283. doi: 10.1016/j.socscimed.2020.113283. Epub 2020 Aug 14.
Providing quality healthcare for homeless patients is a major public health challenge, and some hospitals may be better at treating homeless patients than others. However, whether the quality of care that homeless patients receive differs by the teaching status of hospitals remains unclear. Using statewide databases that include all hospital admissions and emergency department (ED) visits in four states (Florida, Massachusetts, Maryland, and New York) in 2014, we compared 30-day readmission and ED revisit rates for homeless and non-homeless patients discharged from teaching hospitals versus non-teaching hospitals, after adjusting for patient and hospital characteristics. Among 3,438,538 patients (median age [IQR]: 63 [49-77] years) analyzed, 132,025 (4%) were homeless patients. Overall, homeless patients had a higher readmission rate (28.3% vs. 17.7%; average marginal effects [AME], 10.5%; 95% confidence interval [CI], 8.2%-12.9%; p < 0.001) and a higher ED revisit rate (37.6% vs. 23.9%; AME, 13.7%; 95%CI, 10.9%-16.6%; p < 0.001) than non-homeless patients. Patients from teaching hospitals had similar readmission rate (18.2% vs. 18.3%; AME, -0.1%; 95%CI, -0.8%-0.5%; p = 0.69) and slightly lower ED revisit rate than those from non-teaching hospitals (24.1% vs. 25.2%; AME, -1.1%; 95%CI, -1.9% to -0.3%; p < 0.01). When we focus on joint effects of homelessness and hospital teaching status, we found that homeless patients treated at teaching hospitals had lower rates of 30-day readmission (AME, -5.8%; 95%CI, -9.7% to -1.8%; p < 0.01) and ED revisit (AME, -9.3%; 95%CI, -13.1% to -5.5%; p < 0.001) compared to those treated at non-teaching hospitals. For non-homeless patients, in contrast, we found no evidence that rates of hospital readmission (AME, 0%, 95%CI, -0.1%-0.1%; p = 0.94) or ED revisit (AME, -0.9%; 95%CI, -1.7% to -0.1%; p = 0.02) differ between teaching and non-teaching hospitals. These findings suggest the healthcare settings in which homeless patients receive care have important implications for their patient outcomes.
为无家可归的患者提供高质量的医疗保健是一个重大的公共卫生挑战，一些医院在治疗无家可归的患者方面可能比其他医院更有优势。然而，无家可归的患者所接受的护理质量是否因医院的教学地位而异尚不清楚。我们使用包括四个州（佛罗里达州、马萨诸塞州、马里兰州和纽约州）2014 年所有医院入院和急诊（ED）就诊的全州数据库，在调整了患者和医院特征后，比较了从教学医院和非教学医院出院的无家可归和非无家可归患者的 30 天再入院率和 ED 复诊率。在分析的 3438538 名患者（中位数年龄[IQR]：63[49-77]岁）中，有 132025 名（4%）是无家可归的患者。总体而言，无家可归的患者再入院率较高（28.3%比 17.7%；平均边缘效应[AME]，10.5%；95%置信区间[CI]，8.2%-12.9%；p<0.001）和 ED 复诊率较高（37.6%比 23.9%；AME，13.7%；95%CI，10.9%-16.6%；p<0.001）高于非无家可归的患者。来自教学医院的患者再入院率与非教学医院相似（18.2%比 18.3%；AME，-0.1%；95%CI，-0.8%-0.5%；p=0.69），ED 复诊率略低于非教学医院（24.1%比 25.2%；AME，-1.1%；95%CI，-1.9%至-0.3%；p<0.01）。当我们关注无家可归和医院教学地位的共同影响时，我们发现，在教学医院接受治疗的无家可归患者的 30 天再入院率（AME，-5.8%；95%CI，-9.7%至-1.8%；p<0.01）和 ED 复诊率（AME，-9.3%；95%CI，-13.1%至-5.5%；p<0.001）低于在非教学医院接受治疗的患者。相比之下，对于非无家可归的患者，我们没有发现教学医院和非教学医院之间的医院再入院率（AME，0%；95%CI，-0.1%至-0.1%；p=0.94）或 ED 复诊率（AME，-0.9%；95%CI，-1.7%至-0.1%；p=0.02）有差异的证据。这些发现表明，无家可归患者接受治疗的医疗保健环境对他们的患者预后有重要影响。
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