Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.
Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
Int J Chron Obstruct Pulmon Dis. 2021 Feb 2;16:191-202. doi: 10.2147/COPD.S281162. eCollection 2021.
We explored the relationship between rural residency and in-hospital mortality in patients hospitalized with COPD exacerbations.
We retrospectively analyzed COPD hospitalizations from 2011 to 2017 at 124 acute care Veterans Health Administration (VHA) hospitals in the US. Patient residence was classified using Rural Urban Commuting Area codes as urban, rural, or isolated rural. We stratified patient hospitalizations into quartiles by travel time from patient residence to the nearest VHA primary care provider clinic and hospital. Multivariate analyses utilized generalized estimating equations with a logit link accounting for repeated hospitalizations among patients and adjusting for patient- and hospital-level characteristics.
Of 64,914 COPD hospitalizations analyzed, 43,549 (67.1%) were for urban, 18,673 (28.8%) for rural, and 2,692 (4.1%) for isolated rural veterans. In-hospital mortality was 4.9% in urban, 5.5% in rural, and 5.2% in isolated rural veterans (=0.008). Thirty-day mortality was 8.3% in urban, 9.9% in rural, and 9.2% in isolated rural veterans (<0.001). Travel time to a primary care provider and VHA hospital was not associated with in-hospital mortality among isolated rural and rural veterans. In the multivariable analysis, compared to urban veterans, isolated rural patients did not have increased mortality. Rural residence was not associated with in-hospital (OR=0.87; 95% CI=0.67-1.12, =0.28) but was associated with increased 30-day mortality (OR=1.13; 95% CI=1.04-1.22, =0.002). Transfer from another acute care hospital (OR=14.97; 95% CI=9.80-17.16, <0.001) or an unknown/other facility (OR=33.05; 95% CI=22.66-48.21, <0.001) were the strongest predictors of increased in-hospital mortality compared to patients coming from the outpatient sector. Transfer from another acute care facility was also a risk factor for 30-day mortality.
Potential gaps in post-discharge care of rural veterans may be responsible for the rural-urban disparities. Further research should investigate the exact mechanism that inter-hospital transfers affect mortality.
我们探讨了农村居民身份与 COPD 加重患者住院期间院内死亡率之间的关系。
我们回顾性分析了 2011 年至 2017 年期间美国 124 家急性护理退伍军人健康管理局（VHA）医院的 COPD 住院患者。患者居住地使用城乡通勤区代码分为城市、农村或孤立农村。我们根据患者居住地到最近的 VHA 初级保健医生诊所和医院的旅行时间将患者住院情况分为四分位数。多变量分析采用广义估计方程，对数链接考虑了患者的重复住院，并调整了患者和医院层面的特征。
在分析的 64914 例 COPD 住院患者中，43549 例（67.1%）为城市患者，18673 例（28.8%）为农村患者，2692 例（4.1%）为孤立农村退伍军人。城市患者的院内死亡率为 4.9%，农村患者为 5.5%，孤立农村退伍军人为 5.2%（=0.008）。城市患者 30 天死亡率为 8.3%，农村患者为 9.9%，孤立农村退伍军人为 9.2%（<0.001）。农村和农村退伍军人到初级保健医生和 VHA 医院的旅行时间与院内死亡率无关。在多变量分析中，与城市退伍军人相比，孤立农村患者的死亡率没有增加。农村居民身份与院内死亡率无关（OR=0.87；95%CI=0.67-1.12，=0.28），但与 30 天死亡率增加有关（OR=1.13；95%CI=1.04-1.22，=0.002）。从另一家急性护理医院（OR=14.97；95%CI=9.80-17.16，<0.001）或未知/其他机构（OR=33.05；95%CI=22.66-48.21，<0.001）转院是与门诊患者相比，增加院内死亡率的最强预测因素。从另一家急性护理机构转院也是 30 天死亡率的一个危险因素。
农村退伍军人出院后护理方面的潜在差距可能是造成城乡差异的原因。进一步的研究应调查医院间转运会如何影响死亡率的确切机制。
