Hospital Selection Patterns for Emergency Surgical Care: Structural Barriers as a Contributor to Surgical Outcomes.

IF 2.8 2区 医学 Q1 HEALTH CARE SCIENCES & SERVICES
Jiuying Han, Neng Wan, Joshua J Horns, Simon Brewer, Marta L McCrum
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引用次数: 0

Abstract

Background: Structural inequities are pervasive in the US emergency care system and disproportionately affect socially vulnerable neighborhoods. Spatial patterns of hospital access for patients requiring emergency surgical care are influenced by health system structure; however, neighborhood-level variation and its association with clinical outcomes has not yet been characterized.

Objective: Examine variation in spatial patterns of hospital access for adults with nontraumatic surgical emergencies and its association with clinical outcomes.

Design: Retrospective analysis of California State Inpatient Discharge Data (2014-2015) of adults admitted with 1 of 8 emergency general surgery (EGS) conditions. We visualized patient home-to-hospital flows, then assessed Zip Code Tabulation Areas (ZCTA) patterns of spatial access using the Dispersion Index (DI), measured by the coefficient of variation of patient travel times where higher values indicate greater dispersion. Mixed-effect regression analysis was used to examine the association of DI with in-hospital mortality, nonhome discharge, and length of stay, adjusting for relevant patient, hospital, and neighborhood characteristics.

Results: Among 337,695 EGS admissions, increasing DI was associated with greater neighborhood social deprivation index (SDI). After adjusting for relevant covariates, greater dispersion was associated with an increase in in-hospital mortality in the highest decile of dispersion (aOR: 1.14; 95% CI: 1.03-1.26). The magnitude of effect was greater for patients from high-SDI neighborhoods: mortality (aOR: 1.27; 95% CI: 1.11-1.44).

Conclusions: High dispersion was associated with unfavorable clinical outcomes among EGS patients, with a greater effect for underserved groups. High variation in patterns of hospital access for emergency care likely reflects structural barriers to care and may be one mechanism contributing to the relationship between neighborhood social vulnerability and surgical outcomes.

急诊外科护理的医院选择模式:结构障碍对手术结果的影响。
背景:结构性不平等在美国紧急护理系统中普遍存在,并不成比例地影响到社会弱势社区。急诊外科患者就诊空间格局受卫生系统结构影响;然而,社区水平的差异及其与临床结果的关系尚未被描述。目的:研究非创伤性急诊成人住院空间格局的变化及其与临床结果的关系。设计:回顾性分析2014-2015年加利福尼亚州8种急诊普通外科(EGS)病症中1种的成人住院出院数据。我们可视化了患者从家到医院的流动,然后利用离散指数(DI)评估了邮政编码制表区域(ZCTA)的空间访问模式,离散指数是通过患者旅行时间的变异系数来衡量的,数值越高表明离散程度越高。采用混合效应回归分析,在调整相关患者、医院和社区特征后,检验残保与住院死亡率、非家庭出院和住院时间的关系。结果:在337,695例EGS入院患者中,DI的增加与社区社会剥夺指数(SDI)的增加相关。在对相关协变量进行调整后,更大的离散度与离散度最高十分位数的住院死亡率增加相关(aOR: 1.14;95% ci: 1.03-1.26)。来自高sdi社区的患者的影响程度更大:死亡率(aOR: 1.27;95% ci: 1.11-1.44)。结论:在EGS患者中,高离散度与不利的临床结果相关,对服务不足的群体影响更大。急诊就诊模式的高度差异可能反映了护理的结构性障碍,可能是社区社会脆弱性与手术结果之间关系的一种机制。
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来源期刊
Medical Care
Medical Care 医学-公共卫生、环境卫生与职业卫生
CiteScore
5.20
自引率
3.30%
发文量
228
审稿时长
3-8 weeks
期刊介绍: Rated as one of the top ten journals in healthcare administration, Medical Care is devoted to all aspects of the administration and delivery of healthcare. This scholarly journal publishes original, peer-reviewed papers documenting the most current developments in the rapidly changing field of healthcare. This timely journal reports on the findings of original investigations into issues related to the research, planning, organization, financing, provision, and evaluation of health services.
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