Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia.
Division of Gastroenterology, University of Pennsylvania, Philadelphia.
JAMA Surg. 2023 Oct 1;158(10):1023-1030. doi: 10.1001/jamasurg.2023.2742.
Sixty-five million individuals in the US live in primary care shortage areas with nearly one-third of Medicare patients in need of a primary care health care professional. Periodic health examinations and preventive care visits have demonstrated a benefit for surgical patients; however, the impact of primary care health care professional shortages on adverse outcomes from surgery is largely unknown.
To determine if preoperative primary care utilization is associated with postoperative mortality following an emergency general surgery (EGS) operation among Black and White older adults.
DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study that took place at US hospitals with an emergency department. Participants were Medicare patients aged 66 years or older who were admitted from the emergency department for an EGS condition between July 1, 2015, and June 30, 2018, and underwent an operation on hospital day 0, 1, or 2. The analysis was performed during December 2022. Patients were classified into 1 of 5 EGS condition categories based on principal diagnosis codes; colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, or upper gastrointestinal. Mixed-effects multivariable logistic regression was used in the risk-adjusted models. An interaction term model was used to measure effect modification by race.
Primary care utilization in the year prior to presentation for an EGS operation.
In-hospital, 30-day, 60-day, 90-day, and 180-day mortality.
A total of 102 384 patients (mean age, 73.8 [SD, 11.5] years) were included in the study. Of those, 8559 were Black (8.4%) and 93 825 were White (91.6%). A total of 88 340 patients (86.3%) had seen a primary care physician in the year prior to their index hospitalization. After risk adjustment, patients with primary care exposure had 19% lower odds of in-hospital mortality than patients without primary care exposure (odds ratio [OR], 0.81; 95% CI, 0.72-0.92). At 30 days patients with primary care exposure had 27% lower odds of mortality (OR, 0.73; 95% CI, 0.67-0.80). This remained relatively stable at 60 days (OR, 0.75; 95% CI, 0.69-0.81), 90 days (OR, 0.74; 95% CI, 0.69-0.81), and 180 days (OR, 0.75; 95% CI, 0.70-0.81). None of the interactions between race and primary care physician exposure for mortality at any time interval were significantly different.
In this observational study of Black and White Medicare patients, primary care utilization had no impact on in-hospital mortality for Black patients, but was associated with decreased mortality for White patients. Primary care utilization was associated with decreased mortality for both Black and White patients at 30, 60, 90 and 180 days.
美国有 6500 万人居住在初级保健短缺地区，近三分之一的 Medicare 患者需要初级保健医疗专业人员。定期健康检查和预防保健访问已证明对手术患者有益；然而，初级保健医疗专业人员短缺对手术不良结果的影响在很大程度上尚不清楚。
确定在黑人及白人老年患者中，术前是否利用初级保健与急诊普通外科 (EGS) 手术后的死亡率相关。
设计、地点和参与者：这是一项回顾性队列研究，在美国有急诊部的医院进行。参与者为 Medicare 患者，年龄在 66 岁或以上，因 EGS 疾病于 2015 年 7 月 1 日至 2018 年 6 月 30 日从急诊部入院，并于医院日 0、1 或 2 进行手术。分析于 2022 年 12 月进行。根据主要诊断代码，患者被分为 5 种 EGS 疾病类别之一；结直肠、普通腹部、肝胆胰、肠梗阻或上消化道。使用混合效应多变量逻辑回归进行风险调整模型。使用交互项模型来衡量种族对效应修饰的影响。
在进行 EGS 手术前一年利用初级保健。
院内、30 天、60 天、90 天和 180 天的死亡率。
共有 102384 名患者（平均年龄 73.8[标准差 11.5]岁）纳入研究。其中 8559 名为黑人（8.4%），93825 名为白人（91.6%）。共有 88340 名患者（86.3%）在索引住院前一年看过初级保健医生。在风险调整后，与未利用初级保健的患者相比，利用初级保健的患者院内死亡率低 19%（优势比 [OR]，0.81；95%置信区间 [CI]，0.72-0.92）。在 30 天时，利用初级保健的患者的死亡率低 27%（OR，0.73；95% CI，0.67-0.80）。这一比例在 60 天（OR，0.75；95% CI，0.69-0.81）、90 天（OR，0.74；95% CI，0.69-0.81）和 180 天（OR，0.75；95% CI，0.70-0.81）时仍然相对稳定。任何时间间隔种族与初级保健医生利用之间的交互作用都没有显著差异。
在这项针对黑人及白人 Medicare 患者的观察性研究中，初级保健的利用对黑人患者的院内死亡率没有影响，但与白人患者的死亡率降低相关。初级保健的利用与黑人及白人患者在 30、60、90 和 180 天时的死亡率降低有关。
