Black-White disparities in maternal in-hospital mortality according to teaching and Black-serving hospital status.
Black-White disparities in maternal in-hospital mortality according to teaching and Black-serving hospital status.
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DOI：
10.1016/j.ajog.2021.01.004
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发表时间：
2021-07
影响因子：
9.8
通讯作者：
Lorch SA
中科院分区：
文献类型：
--
作者：
Burris HH;Passarella M;Handley SC;Srinivas SK;Lorch SA
在美国，黑人的孕产妇死亡率高于白人。不同医院类型（黑人服务与非黑人服务以及教学与非教学）在分娩住院期间孕产妇住院死亡率方面的黑人和白人差异是否存在差异，以及孕产妇总体死亡率在不同医院类型之间是否存在差异尚不清楚。 1) 确定分娩住院期间孕产妇死亡率的风险调整黑白差异是否因医院类型而异——这是对医院类型内死亡率差异的分析。 2) 比较黑人服务和非黑人服务的教学和非教学医院的风险调整院内孕产妇死亡率，无论种族如何——这是对不同类型医院总体死亡率的分析。我们对 1995 年至 2009 年三个州（加利福尼亚州、密苏里州、宾夕法尼亚州）的 5,679,044 名黑人 (14.2%) 和白人 (85.8%) 患者进行了一项基于人群的回顾性队列研究。出院处理的“死亡”定义了孕产妇住院死亡率。为黑人服务的医院至少有 7% 的黑人产科患者（前四分之一）。我们通过使用逻辑回归模型的预测计算预期死亡率来进行风险调整，其中包含社会人口统计学、农村地区、合并症、多胎妊娠、分娩胎龄、年份、州和分娩方式。我们通过比较不同类型医院内黑人和白人患者的观察值与预期比率，计算了风险调整后的死亡率风险比，然后检查了不同医院类型之间的死亡率，无论患者种族如何。我们使用因果中介分析量化了因在黑人服务医院分娩而导致的黑人和白人死亡率差异的比例。 5,679,044 名患者中有 330 名孕产妇死亡（每 10 万人中有 5.8 人死亡）。黑人患者的死亡率（每 100,000 人 11.5 人）比白人患者（每 100,000 人 4.8 人）死亡率更高（RR 2.38，95% CI：1.89–2.98）。对黑人与白人差异的检查显示，风险调整后，黑人患者的死亡风险显着更高（调整后 RR 1.44，95% CI 1.17-1.79），并且每种医院类型内的差异相似。不同种族的不同医院类型的死亡率比较显示，在教学医院中，为黑人服务的医院和非黑人服务的医院的死亡率相似。然而，在非教学医院中，黑人服务医院的死亡率明显高于非黑人服务医院（调整后的 RR 1.47，95% CI：1.15-1.87）。值得注意的是，53% 的黑人患者在非教学、为黑人服务的医院分娩，而白人患者的这一比例仅为 19%。在非教学医院中，孕产妇住院死亡率的黑人与白人差异的 47% 归因于在黑人服务医院分娩。黑人患者分娩住院期间产妇住院死亡率是白人患者的两倍多。我们的数据表明，这种差异是由于每种医院类型内黑人患者死亡率过高，以及大多数黑人患者分娩的非教学、黑人服务医院死亡率过高造成的。解决种族主义的下游影响以实现孕产妇住院死亡率的公平，需要按种族透明地报告质量指标，以减少医院类型内的差异化护理和结果，改善为黑人服务的医院的护理服务，克服黑人患者获得高质量护理的障碍，并最终废除医疗保健种族隔离。
Maternal mortality is higher among Black compared to White people in the United States. Whether Black-White disparities in maternal in-hospital mortality during the delivery hospitalization vary across hospital types (Black-serving vs. non-Black-serving and teaching vs. non-teaching) and whether overall maternal mortality differs across hospital types is not known. 1) Determine whether risk-adjusted Black-White disparities in maternal mortality during the delivery hospitalization vary by hospital types – this is analysis of disparities in mortality within hospital types. 2) Compare risk-adjusted in-hospital maternal mortality among Black-serving and non-Black-serving teaching and non-teaching hospitals regardless of race – this is an analysis of overall mortality across hospital types. We performed a population-based, retrospective cohort study of 5,679,044 deliveries among Black (14.2%) and White (85.8%) patients in three states (CA, MO, PA) from 1995–2009. A hospital discharge disposition of “death” defined maternal in-hospital mortality. Black-serving hospitals had at least 7% Black obstetric patients (top quartile). We performed risk adjustment by calculating expected death rates using predictions from logistic regression models incorporating sociodemographics, rurality, comorbidities, multiple gestations, gestational age at delivery, year, state, and mode of delivery. We calculated risk-adjusted risk ratios of mortality by comparing observed:expected ratios among Black and White patients within hospital types and then examined mortality across hospital types, regardless of patient race. We quantified the proportion of Black-White disparities in mortality attributable to delivering in Black-serving hospitals using causal mediation analysis. There were 330 maternal deaths among 5,679,044 patients (5.8 per 100,000). Black patients died more often (11.5 per 100,000) than White patients (4.8 per 100,000) (RR 2.38, 95% CI: 1.89–2.98). Examination of Black-White disparities revealed that after risk adjustment, Black patients had significantly greater risk of death (adjusted RR 1.44, 95% CI 1.17–1.79) and that the disparity was similar within each of the hospital types. Comparison of mortality, regardless of race, across hospital types, revealed that among teaching hospitals, mortality was similar in Black-serving and non-Black-serving hospitals. However, among non-teaching hospitals, mortality was significantly higher in Black-serving versus non-Black-serving hospitals (adjusted RR 1.47, 95% CI: 1.15–1.87). Notably, 53% of Black patients delivered in non-teaching, Black-serving hospitals, compared with just 19% of White patients. Among non-teaching hospitals, 47% of Black-White disparities in maternal in-hospital mortality attributable to delivering at Black-serving hospitals. Maternal in-hospital mortality during the delivery hospitalization among Black patients is more than double that of White patients. Our data suggest this disparity is due to both excess mortality among Black patients within each hospital type, in addition to excess mortality in non-teaching, Black-serving hospitals where most Black patients deliver. Addressing downstream effects of racism to achieve equity in maternal in-hospital mortality will require transparent reporting of quality metrics by race to reduce differential care and outcomes within hospital types, improvements in care delivery at Black-serving hospitals, overcoming barriers to accessing high-quality care among Black patients, and eventually desegregation of healthcare.
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影响因子：
3.7
作者：
Akinleye, Dean D.;McNutt, Louise-Anne;McLaughlin, Colleen C.
通讯作者：
McLaughlin, Colleen C.
DOI：
10.1111/j.1471-0528.2001.00224.x
发表时间：
2001-09-01
期刊：
BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY
影响因子：
--
作者：
Bouvier-Colle, MH;El Joud, DO;Palot, M
通讯作者：
Palot, M
影响因子：
9.7
作者：
Dimick, Justin;Ruhter, Joel;Birkmeyer, John D.
通讯作者：
Birkmeyer, John D.
影响因子：
7.2
作者：
Bozzuto, Laura;Passarella, Molly;Srinivas, Sindhu
通讯作者：
Srinivas, Sindhu
影响因子：
3.5
作者：
Hagiwara, Nao;Lafata, Jennifer Elston;Fetters, Michael D.
通讯作者：
Fetters, Michael D.