Gordon H S, Harper D L, Rosenthal G E
Program in Health Care Research, Division of General Internal Medicine, Cleveland Veterans Affairs Medical Center, OH 44106, USA.
JAMA. 1996 Nov 27;276(20):1639-44.
To compare observed, predicted, and risk-adjusted hospital mortality rates in white and African-American patients and to determine whether, as prior studies suggest, African-American patients would have higher predicted risks of death and similar or higher risk-adjusted mortality.
Retrospective cohort study.
Thirty hospitals in northeast Ohio.
A total of 88205 eligible patients consecutively discharged in the years 1991 through 1993 with the following 6 diagnoses: acute myocardial infarction, congestive heart failure, obstructive airways disease, gastrointestinal hemorrhage, pneumonia, and stroke.
We measured predicted risks of death at admission for each diagnosis using validated multivariable models based on standard clinical data abstracted from patients' medical records. We then adjusted in-hospital mortality rates in white and African-American patients for predicted risk of death and other covariates using logistic regression analysis.
Predicted risk of death at admission and observed hospital mortality in white and African-American patients.
Predicted risks of death were lower (P<.001) in African Americans for 4 of the 6 diagnoses. Adjusted odds of hospital death were lower (P<.01) in African Americans for 2 of the 6 diagnoses (congestive heart failure and obstructive airways disease) and similar for the other 4 diagnoses. For all diagnoses, in aggregate, the adjusted odds of hospital death were 13% lower in African-American compared with white patients (multivariable odds ratio, 0.87; 95% confidence interval, 0.80-0.94). Findings were similar if further adjustments were made for differences in length of stay, site of hospitalization, or discharge triage practices.
Contrary to our a priori hypotheses, predicted risks of death and risk-adjusted mortality rates were generally lower in African-American patients. Our finding of lower predicted risk may reflect racial differences in hospital admission practices or in access to outpatient care. However, our findings suggest that, once hospitalized, African-American patients attained similar or better outcomes, as measured by an important measure--hospital mortality.
比较白种人和非裔美国患者观察到的、预测的以及风险调整后的医院死亡率，并确定非裔美国患者是否如既往研究所提示的那样，具有更高的预测死亡风险以及相似或更高的风险调整死亡率。
回顾性队列研究。
俄亥俄州东北部的30家医院。
1991年至1993年间连续出院的共88205例符合条件的患者，患有以下6种诊断疾病：急性心肌梗死、充血性心力衰竭、阻塞性气道疾病、胃肠道出血、肺炎和中风。
我们使用基于从患者病历中提取的标准临床数据的经过验证的多变量模型，测量每种诊断在入院时的预测死亡风险。然后，我们使用逻辑回归分析，对非裔美国患者和白种患者的院内死亡率进行预测死亡风险和其他协变量的调整。
白种人和非裔美国患者入院时的预测死亡风险和观察到的医院死亡率。
在6种诊断中的4种中，非裔美国人的预测死亡风险较低（P<0.001）。在6种诊断中的2种（充血性心力衰竭和阻塞性气道疾病）中，非裔美国人的医院死亡调整比值较低（P<0.01），其他4种诊断则相似。总体而言，对于所有诊断，与白种患者相比，非裔美国患者的医院死亡调整比值低13%（多变量比值比，0.87；95%置信区间，0.80 - 0.94）。如果对住院时间、住院地点或出院分诊方式的差异进行进一步调整，结果相似。
与我们的先验假设相反，非裔美国患者的预测死亡风险和风险调整死亡率通常较低。我们发现预测风险较低可能反映了医院入院做法或门诊医疗可及性方面的种族差异。然而，我们的研究结果表明，一旦住院，以一项重要指标——医院死亡率衡量，非裔美国患者获得了相似或更好的结果。
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