Pediatric Intensive Care Unit Mortality Among Latino Children Before and After a Multilevel Health Care Delivery Intervention
Pediatric Intensive Care Unit Mortality Among Latino Children Before and After a Multilevel Health Care Delivery Intervention
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DOI：
10.1001/jamapediatrics.2014.3789
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发表时间：
2015-04-01
期刊：
影响因子：
26.1
通讯作者：
Juarez, Paul D.
中科院分区：
文献类型：
--
作者：
Anand, Kanwaljeet J. S.;Sepanski, Robert J.;Juarez, Paul D.
健康公平性研究的重点是记录卫生保健差距或了解导致差距的因素，但有限的努力集中在减少儿童的卫生保健差距。拉丁裔儿童的急性和慢性疾病患病率增加;他们对高质量的卫生保健，包括重症监护的获取和其他障碍有限。目的确定儿科重症监护病房的死亡率是否可以通过多级卫生保健提供干预来降低。设计，设置，在一个三级护理的大城市儿童医院，对与儿科重症监护病房死亡率相关的因素进行观察性研究。田纳西州孟菲斯的一家医院参与者是2007年至2009年3年干预前期间从儿科重症监护室出院的18岁以下儿童（n = 3891）和2010年至2012年干预后3年（n = 4179）干预多层次的卫生保健干预，以解决拉丁美洲儿童死亡率增加的几率。主要结果和措施使用多变量logistic回归分析干预前3年（2007-2009年）的死亡率，以控制年龄、性别、种族/民族、疾病严重程度、主要诊断类别、确诊感染和保险状况。从干预后阶段（2010年至2012年）的数据进行了类似的分析，以衡量在卫生保健delivery.RESULTS的变化的影响，未调整的死亡率为白色，非洲裔美国人和拉丁美洲儿童在2007年至2009年分别为3.3%，3.3%和8.6%，分别。在控制了协变量后，白色儿童和非裔美国儿童的死亡率没有差异（比值比[OR]，1.0; 95%CI，0.6-1.7; P = 0.97），但拉丁裔儿童的死亡率高3.7倍（95%CI，1.8-7.5; P <0.001）。一个多层次和多学科的干预措施被启动，以解决这些差异。在干预后阶段，白色、非裔美国人和拉丁美洲儿童的未校正死亡率分别为3.6%、3.2%和4.0%，校正协变量后未观察到差异（OR，0.7; 95%CI，0.2-2.1; P = 0.49）。拉丁裔儿童的死亡率在干预前后有所下降（OR，0.24; 95% CI，0.06-0.88; P = 0.03），但白色和非裔美国儿童保持不变（OR，1.02; 95%CI，0.73-1.43; P = 0.90）.结论和相关性拉丁裔儿童有较高的死亡率，即使在控制了年龄，性别，疾病的严重程度，保险状况和其他协变量。在多个层面采取对文化和语言敏感的干预措施后，这些差异消失了。地方多层次的干预措施可以减少医疗不公平对临床结果的影响，而不需要在医疗政策的重大变化。
IMPORTANCE Research on health equity has focused on documenting health care disparities or understanding factors leading to disparities, but limited efforts have focused on reducing health care disparities in children. Latino children have increased prevalence of acute and chronic conditions; they have limited access and other barriers to high-quality health care, including intensive care.OBJECTIVE To determine whether pediatric intensive care unit mortality can be reduced by a multilevel health care delivery intervention.DESIGN, SETTING, AND PARTICIPANTS Observational study of factors associated with pediatric intensive care unit mortality at a tertiary care metropolitan children's hospital in Memphis, Tennessee. Participants were children younger than 18 years discharged from the pediatric intensive care unit during the 3-year preintervention period of 2007 to 2009 (n = 3891) and 3-year postintervention period of 2010 to 2012 (n = 4179).INTERVENTIONS Multilevel health care intervention to address the increased odds of mortality among Latino children.MAIN OUTCOMES AND MEASURES The odds of mortality were analyzed over the 3-year preintervention period (2007-2009) using multivariable logistic regressions to control for age, sex, race/ethnicity, severity of illness, major diagnostic categories, diagnosed infections, and insurance status. Data from the postintervention period (2010-2012) were analyzed similarly to measure the effect of changes in health care delivery.RESULTS Unadjusted mortality rates for white, African American, and Latino children in 2007 to 2009 were 3.3%, 3.3%, and 8.6%, respectively. After controlling for covariates, no differences in the odds of mortalitywere observed between white children and African American children (odds ratio [OR], 1.0; 95% CI, 0.6-1.7; P = .97), but Latino children had 3.7-fold (95% CI, 1.8-7.5; P < .001) higher odds of mortality. A multilevel and multidisciplinary interventionwas launched to address these differences. In the postintervention period, unadjusted mortality rates for white, African American, and Latino children were 3.6%, 3.2%, and 4.0%, respectively, with no differences observed after adjustment for covariates (OR, 0.7; 95% CI, 0.2-2.1; P = .49). The odds of mortality decreased between the preintervention period and postintervention period for Latino children (OR, 0.24; 95% CI, 0.06-0.88; P = .03) but remained unchanged for white and African American children (OR, 1.02; 95% CI, 0.73-1.43; P = .90).CONCLUSIONS AND RELEVANCE Latino children had higher odds of mortality, even after controlling for age, sex, severity of illness, insurance status, and other covariates. These differences disappeared after culturally and linguistically sensitive interventions at multiple levels. Local multilevel interventions can reduce the effect of health care inequities on clinical outcomes, without requiring major changes in health care policy.