Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
J Eval Clin Pract. 2023 Sep;29(6):955-963. doi: 10.1111/jep.13815. Epub 2023 Feb 19.
To examine the impact of socioeconomic status (SES) and postacute care (PAC) locations on the association between hospital safety-net status and 30-day postdischarge outcomes (readmission, hospice use, or death).
Medicare Current Beneficiary Survey (MCBS) participants during 2006-2011 who were Medicare Fee-for-Service beneficiaries aged 65.5 years or older were included. The associations between hospital safety-net status and 30-day post-discharge outcomes were evaluated by comparing the models with and without PAC and SES adjustments. Safety-net hospital status was defined as being in the top 20% of hospitals ranked by hospital-level percent of total Medicare patient days. SES was measured using individual-level SES (dual eligibility, income, and education) and the Area Deprivation Index (ADI).
This study identified 13,173 index hospitalizations for 6,825 patients; 1,428 hospitalizations (11.8%) were in safety-net hospitals. The average unadjusted 30-day hospital readmission rate was 22.6% in safety-net hospitals versus 18.8% in nonsafety-net hospitals. Regardless of whether patient SES status was controlled or not, safety-net hospitals had higher estimated probabilities of 30-day readmission (ranging from 0.217 to 0.222 vs. 0.184 to 0.189), and lower probabilities for having neither readmission nor hospice/death (0.750-0.763 vs. 0.780-0.785); for models additionally adjusted for PAC types, safety-net patients had lower rates of hospice use or death (0.019-0.027 vs. 0.030-0.031).
The results suggested that safety-net hospitals had lower hospice/death rates but higher readmission rates relative to outcomes at nonsafety-net hospitals. Readmission rate differences were similar regardless of patients' SES status. However, the rate of hospice referral or death rate was related to SES, which suggested that the outcomes were affected by SES and PAC types.
考察社会经济地位（SES）和急性后期护理（PAC）地点对医院安全网状况与 30 天出院后结局（再入院、使用临终关怀或死亡）之间关联的影响。
纳入 2006 年至 2011 年期间 Medicare 现行受益人调查（MCBS）中的 Medicare 按服务收费受益人和年龄在 65.5 岁及以上的老年人。通过比较有和没有 PAC 和 SES 调整的模型，评估医院安全网状况与 30 天出院后结局之间的关联。安全网医院状况定义为按医院层面 Medicare 患者总天数比例排名前 20%的医院。SES 采用个体层面 SES（双重资格、收入和教育）和区域贫困指数（ADI）来衡量。
本研究共确定了 13173 例索引住院，涉及 6825 名患者；其中 1428 例（11.8%）住院在安全网医院。安全网医院的 30 天医院再入院率平均为 22.6%，而非安全网医院为 18.8%。无论是否控制患者 SES 状况，安全网医院的 30 天再入院估计概率均较高（范围为 0.217 至 0.222，而非安全网医院为 0.184 至 0.189），而既无再入院也无临终关怀/死亡的概率较低（0.750 至 0.763，而非安全网医院为 0.780 至 0.785）；对于另外调整 PAC 类型的模型，安全网患者使用临终关怀或死亡的比例较低（0.019 至 0.027，而非安全网医院为 0.030 至 0.031）。
结果表明，安全网医院的临终关怀/死亡率较低，但与非安全网医院相比，再入院率较高。无论患者 SES 状况如何，再入院率差异相似。然而，临终关怀转诊或死亡率与 SES 有关，这表明结局受到 SES 和 PAC 类型的影响。
