Medvedovsky Steven, Sharath Sherene E, Kougias Panos
Department of Surgery, State University of New York, Downstate Health Sciences University, Brooklyn.
Department of Epidemiology and Biostatistics, State University of New York, Downstate Health Sciences University, Brooklyn.
JAMA Surg. 2025 Apr 1;160(4):442-449. doi: 10.1001/jamasurg.2024.6394.
Chronic limb-threatening ischemia (CLTI) is a major public health issue that requires considerable human and physical resources to provide optimal patient care. It is essential to characterize the disease severity and resource needs of patients with CLTI presenting to facilities of varying resource capacities.
To investigate the association between facility-level Medicaid payer proportions and the incidence of nonelective admissions among patients admitted for CLTI.
DESIGN, SETTING, AND PARTICIPANTS: In this retrospective multicenter cohort study, 876 026 CLTI-related inpatient admissions at 8769 US facilities from January 1, 1998, through October 31, 2020, were identified in the National Inpatient Sample. Facilities were ranked into quintiles according to increasing Medicaid burden, defined as the annualized proportion of Medicaid patient discharges for all hospitalizations. Inpatient admissions for CLTI were identified using International Classification of Diseases codes for rest pain, foot ulcers, and gangrene. Patients younger than 18 years or older than 100 years were excluded, as were those with missing admission type. Statistical analysis was conducted from January to August 2024.
Facility-level Medicaid burden quintiles.
Emergency and urgent admissions defined as nonelective admissions.
The study included 876 026 CLTI-related admissions (mean [SD] patient age, 68.6 [14.5] years; 54.3% men). Increasing nonelective admission rates were associated with increasing facility Medicaid burden (low Medicaid burden, 59.7%; low-moderate Medicaid burden, 62.2%; moderate Medicaid burden, 63.6%; moderate-high Medicaid burden, 63.6%; and high Medicaid burden, 66.8%; P < .001). This trend persisted across all CLTI-related diagnoses (patients with rest pain: low Medicaid burden, 29.8%; high Medicaid burden, 36.1%; patients with lower-limb ulceration: low Medicaid burden, 63.5%; high Medicaid burden, 71.5%; and patients with gangrene: low Medicaid burden, 61.2%; high Medicaid burden, 67.4%; P < .001). In the adjusted model, odds of nonelective admission for CLTI indications increased progressively among facilities as Medicaid burden increased from low to high (adjusted odds ratio for low-moderate Medicaid burden, 1.05 [95% CI, 1.00-1.11]; P = .06; adjusted odds ratio for high Medicaid burden, 1.44 [95% CI, 1.36-1.52]; P < .001).
High Medicaid burden facilities were associated with increased nonelective admissions for CLTI. This highlights an important mismatch: that resource-constrained facilities are at greater odds of seeing more resource-intensive admissions. Facility-level patient cohort characteristics should be considered when planning for resource allocation to achieve equitable patient care.
慢性肢体威胁性缺血（CLTI）是一个重大的公共卫生问题，需要大量人力和物力资源来为患者提供最佳护理。对就诊于不同资源能力医疗机构的CLTI患者的疾病严重程度和资源需求进行特征描述至关重要。
研究医疗机构层面医疗补助计划支付者比例与因CLTI入院患者的非选择性入院发生率之间的关联。
设计、设置和参与者：在这项回顾性多中心队列研究中，利用国家住院样本确定了1998年1月1日至2020年10月31日期间美国8769家医疗机构的876026例与CLTI相关的住院病例。根据医疗补助负担的增加将医疗机构分为五个五分位数组，医疗补助负担定义为所有住院病例中医疗补助患者出院的年化比例。使用国际疾病分类代码确定因静息痛、足部溃疡和坏疽导致的CLTI住院病例。排除年龄小于18岁或大于100岁的患者以及入院类型缺失的患者。于2024年1月至8月进行统计分析。
医疗机构层面的医疗补助负担五分位数组。
定义为非选择性入院的急诊和紧急入院。
该研究纳入了876026例与CLTI相关的入院病例（患者平均年龄[标准差]为68.6[14.5]岁；54.3%为男性）。非选择性入院率的增加与医疗机构医疗补助负担的增加相关（低医疗补助负担组为59.7%；低-中度医疗补助负担组为62.2%；中度医疗补助负担组为63.6%；中度-高医疗补助负担组为63.6%；高医疗补助负担组为66.8%；P＜0.001）。这一趋势在所有与CLTI相关的诊断中均持续存在（静息痛患者：低医疗补助负担组为29.8%；高医疗补助负担组为36.1%；下肢溃疡患者：低医疗补助负担组为63.5%；高医疗补助负担组为71.5%；坏疽患者：低医疗补助负担组为61.2%；高医疗补助负担组为67.4%；P＜0.001）。在调整模型中，随着医疗补助负担从低到高增加，因CLTI指征进行非选择性入院的几率在医疗机构中逐渐增加（低-中度医疗补助负担组的调整优势比为1.05[95%置信区间，1.00-1.11]；P = 0.06；高医疗补助负担组的调整优势比为1.44[95%置信区间，1.36-1.52]；P＜0.001）。
高医疗补助负担的医疗机构与CLTI的非选择性入院增加相关。这凸显了一个重要的不匹配情况：资源受限的医疗机构更有可能接收更多资源密集型的入院病例。在规划资源分配以实现公平的患者护理时，应考虑医疗机构层面的患者队列特征。
