Cambron Julia Claire, Shalen Evan F, McGrath Lidija B, Ramsey Katrina, Khan Abigail
Department of Medicine, Oregon Health and Science University, Portland, OR, USA.
Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA.
Int J Cardiol Congenit Heart Dis. 2024 Sep 19;18:100543. doi: 10.1016/j.ijcchd.2024.100543. eCollection 2024 Dec.
Adults with congenital heart disease (CHD) represent a heterogeneous and growing population with high healthcare utilization. We sought to understand the association between insurance type, healthcare use, and outcomes among adults with CHD in Oregon.
The Oregon All Payers All Claims database from 2010 to 2017 was queried for adults aged 18-65 in 2014 with ICD-9 or 10 codes consistent with CHD; patient demographics, comorbidities, healthcare use, and disease severity were identified. Insurance type was categorized as either public (Medicare and Medicaid) or private (commercial). Descriptive statistics were used to compare groups. Use rates and odds ratios were calculated representing probability of at least one event per person-year using logistic regression with clustering on patients.
Of 13,792 adults with CHD, 48 % had a form of public insurance. More publicly insured patients had moderate or severe anatomic complexity (29.5 % vs. 23.0 %; p < 0.0001), treatment for drug and alcohol use (25.0 % vs. 7.2 %; p < 0.0001), and mental health diagnoses (66.6 % vs. 51.0 %; p < 0.0001). They were more likely to reside in a rural area (24.5 % vs. 16.1 %; p < 0.0001). Adjusted for age and CHD severity, publicly insured patients were less likely to access overall ambulatory care (aOR 0.72, 99 % CI 0.66 to 0.80) but more likely to access emergency (aOR 3.86, 99 % CI 3.62 to 4.12) and inpatient (aOR 3.06, 99 % CI 2.81 to 3.33) care, as shown in Fig. 1. Length of hospital stay (5.7 vs. 4.4 days, p < 0.0001) and rates of 30-day readmission (17.1 % vs. 11.0 %, p < 0.001) were higher in those with public insurance. However, individuals with public insurance were significantly more likely to undergo their annual guideline-indicated echocardiogram (aOR 1.49, 99 % CI 1.23 to 1.80) and attend their annual ACHD visits (aOR 1.62, 99 % CI 1.40 to 1.87).
Our study shows that publicly insured adults with CHD in Oregon have more anatomically complex disease, more comorbidities, and higher healthcare use. While they were more likely to receive guideline-indicated ACHD care, they were also higher utilizers of emergency room and inpatient resources, implying that they may benefit from targeted interventions to improve outcomes and decrease unplanned healthcare use.
患有先天性心脏病（CHD）的成年人是一个异质性且规模不断增长的群体，医疗保健利用率很高。我们试图了解俄勒冈州患有CHD的成年人的保险类型、医疗保健使用情况与预后之间的关联。
查询了2010年至2017年的俄勒冈州全支付方全索赔数据库，以获取2014年年龄在18 - 65岁且国际疾病分类第九版（ICD - 9）或第十版（ICD - 10）编码与CHD一致的成年人；确定了患者的人口统计学特征、合并症、医疗保健使用情况和疾病严重程度。保险类型分为公共保险（医疗保险和医疗补助）或私人保险（商业保险）。使用描述性统计来比较各组。使用逻辑回归并对患者进行聚类分析，计算使用率和比值比，以表示每人每年至少发生一次事件的概率。
在13792名患有CHD的成年人中，48%拥有某种形式的公共保险。更多拥有公共保险的患者患有中度或重度解剖复杂性疾病（29.5%对23.0%；p < 0.0001）、接受过药物和酒精使用治疗（25.0%对7.2%；p < 0.0001）以及有心理健康诊断（66.6%对51.0%；p < 0.0001）。他们更有可能居住在农村地区（24.5%对16.1%；p < 0.0001）。在对年龄和CHD严重程度进行调整后，拥有公共保险的患者获得总体门诊护理的可能性较小（调整后比值比[aOR]为0.72，99%置信区间[CI]为0.66至0.80），但获得急诊（aOR为3.86，99% CI为3.62至4.12）和住院（aOR为3.06，99% CI为2.81至3.33）护理的可能性更大，如图1所示。拥有公共保险的患者的住院时间（5.7天对4.4天，p < 0.0001）和30天再入院率（17.1%对11.0%，p < 0.001）更高。然而，拥有公共保险的个体进行年度指南推荐的超声心动图检查（aOR为1.49，99% CI为1.23至1.80）和参加年度先天性心脏病门诊（aOR为1.62，99% CI为1.40至1.87）的可能性显著更高。
我们的研究表明，俄勒冈州拥有公共保险的患有CHD的成年人患有解剖结构更复杂的疾病、合并症更多且医疗保健利用率更高。虽然他们更有可能接受指南推荐的先天性心脏病护理，但他们也是急诊室和住院资源的更高使用者，这意味着他们可能受益于针对性干预措施，以改善预后并减少非计划性医疗保健使用。
