美国急性缺血性脑卒中患者院内转院的种族、民族、性别和社会经济不平等现象
Race, Ethnic, Sex, and Socioeconomic Inequities in Interhospital Transfer for Acute Ischemic Stroke in the United States.
机构信息
Department of Neurology (D.M.O., A.T.), University of Southern California, Los Angeles.
Department of Medicine, University of California, Los Angeles (D.M.).
出版信息
Stroke. 2023 May;54(5):1320-1329. doi: 10.1161/STROKEAHA.122.038133. Epub 2023 Apr 6.
BACKGROUND
Patients with stroke in the United States can be transferred for higher level of care. Little is known about possible inequities in interhospital transfers (IHTs) for acute ischemic stroke. We hypothesized that historically marginalized populations would have lower odds of IHT.
METHODS
A cross-sectional analysis was done for adults with a primary diagnosis of acute ischemic stroke in 2010 to 2017; n=747 982 were identified in the National Inpatient Sample. Yearly rates for IHT were assessed and adjusted odds ratios (aORs) of IHT in 2014 to 2017 were compared with that of 2010 to 2013. Multinomial logistic regression was used to determine the aOR of IHT, adjusting for sociodemographic variables (model 1), sociodemographic and medical variables such as comorbidity and mortality risk (model 2), and sociodemographic, medical, and hospital variables (model 3).
RESULTS
After adjusting for sociodemographic, medical, and hospital characteristics, there were no significant temporal differences in IHT from 2010 to 2017. Overall, women were less likely than men to be transferred in all models (model 3: aOR, 0.89 [0.86-0.92]). Compared with those who were White, individuals who were Black (aOR, 0.93 [0.88-0.99]), Hispanic (aOR, 0.90 [0.83-0.97]), other (aOR, 0.90 [0.82-0.99]), or of unknown race, ethnicity (aOR, 0.89 [0.80-1.00]) were less likely to be transferred (model 2), but these differences dissipated when further adjusting for hospital-level characteristics (model 3). Compared with those with private insurance, those with Medicaid (aOR, 0.86 [0.80-0.91]), self-pay (aOR, 0.64 [0.59-0.70]), and no charge (aOR, 0.64 [0.46-0.88]) were less likely to be transferred (model 3). Individuals with lower income were less likely to be transferred compared with those with higher income (model 3: aOR, 0.85 [0.80-0.90], third versus fourth quartile).
CONCLUSIONS
Adjusted odds of IHT for acute ischemic stroke remained stable from 2010 to 2017. There are numerous inequities in the rates of IHT by race, ethnicity, sex, insurance, and income. Further studies are needed to understand these inequities and develop policies and interventions to mitigate them.
背景
在美国，患有中风的患者可以转往更高水平的医疗机构进行治疗。对于急性缺血性中风的医院间转院（IHT），人们知之甚少。我们假设历史上处于边缘地位的人群的 IHT 可能性较低。
方法
对 2010 年至 2017 年期间患有急性缺血性中风的成年患者进行了一项横断面分析；在国家住院样本中确定了 747982 名患者。评估了 IHT 的年发生率，并比较了 2014 年至 2017 年与 2010 年至 2013 年的 IHT 调整后比值比（aOR）。使用多项逻辑回归来确定 IHT 的 aOR，调整了社会人口统计学变量（模型 1）、合并症和死亡率风险等社会人口统计学和医疗变量（模型 2）以及社会人口统计学、医疗和医院变量（模型 3）。
结果
在调整了社会人口统计学、医疗和医院特征后，2010 年至 2017 年 IHT 没有明显的时间差异。总体而言，在所有模型中，女性转移的可能性均低于男性（模型 3：aOR，0.89 [0.86-0.92]）。与白人相比，黑人（aOR，0.93 [0.88-0.99]）、西班牙裔（aOR，0.90 [0.83-0.97]）、其他种族（aOR，0.90 [0.82-0.99]）或未知种族和民族（aOR，0.89 [0.80-1.00]）的个体转院的可能性较低（模型 2），但进一步调整医院水平特征后，这些差异消失（模型 3）。与私人保险相比，医疗补助（aOR，0.86 [0.80-0.91]）、自付（aOR，0.64 [0.59-0.70]）和无费用（aOR，0.64 [0.46-0.88]）的个体转院的可能性较低（模型 3）。与高收入者相比，低收入者转院的可能性较低（模型 3：aOR，0.85 [0.80-0.90]，第三四分位与第四四分位）。
结论
2010 年至 2017 年，急性缺血性中风的 IHT 调整后几率保持稳定。在种族、民族、性别、保险和收入方面，IHT 的发生率存在许多不平等现象。需要进一步研究以了解这些不平等现象，并制定政策和干预措施来减轻这些不平等现象。
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