Do hospitals provide lower quality of care to black patients for pneumonia?
Do hospitals provide lower quality of care to black patients for pneumonia?
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DOI：
10.1097/ccm.0b013e3181c8fd58
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发表时间：
2010-03
影响因子：
8.8
通讯作者：
Angus DC
中科院分区：
文献类型：
--
作者：
Mayr FB;Yende S;D'Angelo G;Barnato AE;Kellum JA;Weissfeld L;Yealy DM;Reade MC;Milbrandt EB;Angus DC
最近的研究报告称，与白人相比，黑人社区获得性肺炎患者的护理质量较低，并表明各个医院层面仍然存在差异。我们研究了急诊科和重症监护室护理流程中的种族差异，以确定在调整病例组合和各医院护理差异后是否仍然存在差异。前瞻性、观察性队列研究。美国二十八家医院。社区获得性肺炎患者：1738 名白人患者和 352 名黑人患者。没有任何。我们根据 4 小时内接受抗生素和遵守美国胸科学会抗生素指南的情况来比较护理质量，并根据重症监护室入院和机械通气的使用情况来比较护理强度。使用随机效应和广义估计方程模型，我们对医院内的病例组合和种族群体聚类进行了调整，并估计了医院内和医院间护理差异的比值比。黑人患者在 4 小时内接受抗生素治疗的可能性较小（比值比，0.55；95% 置信区间，0.43–0.70；p < .001），并且不太可能接受遵循指南的抗生素治疗（比值比，0.72；95% 置信区间，0.57–0.91；p = .006）。调整病例组合后，这些差异有所减弱（优势比，0.59；95% 置信区间；0.46-0.76 和 0.84；95% 置信区间，0.66-1.09）。在医院内，黑人和白人患者接受相似的护理质量（比值比，1；95% 置信区间，0.97–1.04 和 1；95% 置信区间，0.97–1.03）。然而，服务较多黑人患者的医院不太可能及时提供抗生素（比值比，0.84；95% 置信区间，0.78-0.90）。黑人患者更有可能接受机械通气（比值比，1.57；95% 置信区间，1.02–2.42；p = .042）。同样，在医院内，黑人和白人受试者接受机械通气的可能性相同（比值比，1；95% 置信区间，0.94–1.06），而为黑人患者比例较高的医院提供机械通气的可能性更大（比值比，1.13；95% 置信区间，1.02–1.25）。粗略分析显示，黑人患者接受的护理质量似乎较低，但护理强度较高。然而，这些差异是由于不同医院的病例组合和护理差异造成的。在同一家医院内，没有观察到护理方面的种族差异。
Recent studies reported lower quality of care for black vs. white patients with community-acquired pneumonia and suggested that disparities persist at the individual hospital level. We examined racial differences in emergency department and intensive care unit care processes to determine whether differences persist after adjusting for case-mix and variation in care across hospitals. Prospective, observational cohort study. Twenty-eight U.S. hospitals. Patients with community-acquired pneumonia: 1738 white and 352 black patients. None. We compared care quality based on antibiotic receipt within 4 hrs and adherence to American Thoracic Society antibiotic guidelines, and intensity based on intensive care unit admission and mechanical ventilation use. Using random effects and generalized estimating equations models, we adjusted for case-mix and clustering of racial groups within hospitals and estimated odds ratios for differences in care within and across hospitals. Black patients were less likely to receive antibiotics within 4 hrs (odds ratio, 0.55; 95% confidence interval, 0.43–0.70; p < .001) and less likely to receive guideline-adherent antibiotics (odds ratio, 0.72; 95% confidence interval, 0.57–0.91; p = .006). These differences were attenuated after adjusting for casemix (odds ratio, 0.59; 95% confidence interval; 0.46–0.76 and 0.84; 95% confidence interval, 0.66 –1.09). Within hospitals, black and white patients received similar care quality (odds ratio, 1; 95% confidence interval, 0.97–1.04 and 1; 95% confidence interval, 0.97–1.03). However, hospitals that served a greater proportion of black patients were less likely to provide timely antibiotics (odds ratio, 0.84; 95% confidence interval, 0.78–0.90). Black patients were more likely to receive mechanical ventilation (odds ratio, 1.57; 95% confidence interval, 1.02–2.42; p = .042). Again, within hospitals, black and white subjects were equally likely to receive mechanical ventilation (odds ratio, 1; 95% confidence interval, .94–1.06) and hospitals that served a greater proportion of black patients were more likely to institute mechanical ventilation (odds ratio, 1.13; 95% confidence interval, 1.02–1.25). Black patients appear to receive lower quality and higher intensity of care in crude analyses. However, these differences were explained by different case-mix and variation in care across hospitals. Within the same hospital, no racial differences in care were observed.