脊髓损伤后撤除生命支持和死亡率中与保险有关的差异。

IF 15.7 1区 医学 Q1 SURGERY JAMA surgery Pub Date : 2024-10-01 DOI:10.1001/jamasurg.2024.2967
Husain Shakil, Ahmad Essa, Armaan K Malhotra, Rachael H Jaffe, Christopher W Smith, Eva Y Yuan, Yingshi He, Jetan H Badhiwala, François Mathieu, Michael C Sklar, Duminda N Wijeysundera, Karim Ladha, Avery B Nathens, Jefferson R Wilson, Christopher D Witiw
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引用次数: 0

摘要

重要性:确定与可改变的患者因素相关的健康结果差异可以改善患者护理:比较不同保险类型的完全性颈椎脊髓损伤(SCI)患者退出生命支持治疗(WLST)的可能性和死亡率:这项回顾性队列研究收集了 2013 年至 2020 年期间参与 "创伤质量改进计划 "的 498 家创伤中心的数据。参与者包括完全性颈椎 SCI 的成年患者(16 岁以上)。数据分析时间为 2023 年 11 月 1 日至 2024 年 5 月 18 日。风险暴露:无保险或公共保险与私人保险的比较:主要结果和测量指标:主要结果为WLST和死亡率。采用分层逻辑回归法估算每个结果的调整后几率比(aOR)。倾向评分匹配作为一种替代分析方法,用于比较公共保险和私人保险患者。比较了匹配患者的护理过程结果,包括住院并发症发生率和住院时间:研究纳入了在 498 家创伤中心接受治疗的 8421 名完全性颈椎 SCI 患者(平均 [SD] 年龄为 49.1 [20.2] 岁;6742 名男性 [80.1%])。在 3524 名购买了私人保险的患者中,503 人接受了 WLST(14.3%),756 人死亡(21.5%)。在 3957 名购买了公共保险的患者中,906 人(22.2%)患有 WLST,1209 人(30.6%)死亡。在 940 名未参保的患者中,156 人(16.6%)接受了 WLST,318 人(33.8%)死亡。在调整后的 WLST 发生几率(aOR,1.49;95% CI,1.11-2.01)和死亡率(aOR,1.98;95% CI,1.50-2.60)方面,未参保患者和私人参保患者之间存在明显差异。在分组分析中也发现了类似的结果。与私人保险患者相比,匹配的公共保险患者出现住院并发症的几率明显更高(几率比1.27;95% CI,1.14-1.42),住院时间更长(平均差异5.90天;95% CI,4.64-7.20),这一点在亚组分析中再次得到证实:在本研究中,医疗保险类型与完全性颈椎 SCI 患者发生 WLST 的几率、死亡率、住院并发症和住院天数的显著差异有关。今后的工作需要纳入患者的观点,并确定策略以缩小大量无私人保险患者的质量差距。
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Insurance-Related Disparities in Withdrawal of Life Support and Mortality After Spinal Cord Injury.

Importance: Identifying disparities in health outcomes related to modifiable patient factors can improve patient care.

Objective: To compare likelihood of withdrawal of life-supporting treatment (WLST) and mortality in patients with complete cervical spinal cord injury (SCI) with different types of insurance.

Design, setting, and participants: This retrospective cohort study collected data between 2013 and 2020 from 498 trauma centers participating in the Trauma Quality Improvement Program. Participants included adult patients (older than 16 years) with complete cervical SCI. Data were analyzed from November 1, 2023, through May 18, 2024.

Exposure: Uninsured or public insurance compared with private insurance.

Main outcomes and measures: Coprimary outcomes were WLST and mortality. The adjusted odds ratio (aOR) of each outcome was estimated using hierarchical logistic regression. Propensity score matching was used as an alternative analysis to compare public and privately insured patients. Process of care outcomes, including the occurrence of a hospital complication and length of stay, were compared between matched patients.

Results: The study included 8421 patients with complete cervical SCI treated across 498 trauma centers (mean [SD] age, 49.1 [20.2] years; 6742 male [80.1%]). Among the 3524 patients with private insurance, 503 had WLST (14.3%) and 756 died (21.5%). Among the 3957 patients with public insurance, 906 had WLST (22.2%) and 1209 died (30.6%). Among the 940 uninsured patients, 156 had WLST (16.6%) and 318 died (33.8%). A significant difference was found between uninsured and privately insured patients in the adjusted odds of WLST (aOR, 1.49; 95% CI, 1.11-2.01) and mortality (aOR, 1.98; 95% CI, 1.50-2.60). Similar results were found in subgroup analyses. Matched public compared with private insurance patients were found to have significantly greater odds of hospital complications (odds ratio, 1.27; 95% CI, 1.14-1.42) and longer hospital stay (mean difference 5.90 days; 95% CI, 4.64-7.20), which was redemonstrated on subgroup analyses.

Conclusions and relevance: Health insurance type was associated with significant differences in the odds of WLST, mortality, hospital complications, and days in hospital among patients with complete cervical SCI in this study. Future work is needed to incorporate patient perspectives and identify strategies to close the quality gap for the large number of patients without private insurance.

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来源期刊
JAMA surgery
JAMA surgery SURGERY-
CiteScore
20.80
自引率
3.60%
发文量
400
期刊介绍: JAMA Surgery, an international peer-reviewed journal established in 1920, is the official publication of the Association of VA Surgeons, the Pacific Coast Surgical Association, and the Surgical Outcomes Club.It is a proud member of the JAMA Network, a consortium of peer-reviewed general medical and specialty publications.
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