Disparities in Care and Mortality Among Homeless Adults Hospitalized for Cardiovascular Conditions
Disparities in Care and Mortality Among Homeless Adults Hospitalized for Cardiovascular Conditions
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DOI：
10.1001/jamainternmed.2019.6010
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发表时间：
2020-03-01
影响因子：
39
通讯作者：
Joynt Maddox, Karen E.
中科院分区：
文献类型：
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作者：
Wadhera, Rishi K.;Khatana, Sameed Ahmed M.;Joynt Maddox, Karen E.
重要性 心血管疾病是无家可归成年人死亡的主要原因，其死亡率远高于一般人群。目前尚不清楚住院相关护理的差异是否会导致心血管结局的差异。目的 评估因心血管疾病（即急性心肌梗塞、中风、心脏骤停或心力衰竭）住院的无家可归者和非无家可归者之间的护理强度和死亡率的差异。设计、设置和参与者 这项回顾性横断面研究包括 2010 年 1 月 1 日至 2015 年 9 月 30 日期间纽约州、马萨诸塞州和佛罗里达州 18 岁或以上无家可归成年人 (n = 24 890) 和非无家可归成年人 (n = 1 827 900) 因心血管疾病住院的所有情况。统计分析于 2019 年 2 月 6 日至 7 月 16 日进行。结果和措施 风险标准化诊断和治疗手术率以及院内死亡率。结果 在 525 家医院因心血管疾病住院的 1 852 790 例患者中，24 890 例发生在无家可归的患者中（11 452 名女性和 13 438 名男性；平均 [SD] 年龄为 65.1 [14.8] 岁），1 827 900 例发生在非无家可归的患者中（850 660 名女性和 977 240 名男性；平均 [SD] 年龄为 65.1 [14.8] 岁）。平均 [SD] 年龄，72.1 [14.6] 岁）。大多数无家可归者的住院治疗主要集中在 11 家医院。无家可归的成年人比非无家可归的成年人更有可能是黑人（38.6% vs 15.6%）并且有医疗补助保险（49.3% vs 8.5%）。考虑到人口统计学（年龄、性别和种族/民族）、保险支付者和临床合并症的差异后，与非无家可归的成年人相比，因急性心肌梗死住院的无家可归的成年人接受冠状动脉造影的可能性较小（39.5% vs 70.9%；P < .001）、经皮冠状动脉介入治疗（24.8% vs 47.4%；P < .001）和冠状动脉旁路移植术（2.5% 与 7.0%；P < .001）。在因中风住院的成人中，无家可归者接受脑血管造影的可能性低于非无家可归者（2.9% vs 9.5%；P < .001），但接受溶栓治疗的可能性相同（4.8% vs 5.2%；P = .28）。在心脏骤停队列中，无家可归的成年人比非无家可归的成年人接受冠状动脉造影（10.1% vs 17.6%；P < .001）和经皮冠状动脉介入治疗（0.0% vs 4.7%；P < .001）的可能性更低。与非无家可归者相比，患有 ST 段抬高型心肌梗死的无家可归者的风险标准化死亡率较高（8.3% vs 6.2%；P = .04）。无家可归者的死亡率也高于因中风住院的非无家可归者（8.9% vs 6.3%；P < .001）或心脏骤停（76.1% vs 57.4%；P < .001），但心力衰竭的死亡率没有差异（1.6% vs 1.6%；P = .83）。结论和相关性 患有心血管疾病的无家可归者和非无家可归者之间的住院治疗和死亡率存在显着差异。需要公共卫生和政策努力来支持照顾无家可归者的医院，以减少医院护理的差异并改善该人群的健康结果。这项横断面研究评估了因急性心肌梗死、中风、心脏骤停或心力衰竭住院的无家可归者和非无家可归者之间的护理强度和死亡率的差异。问题 因急性心血管疾病住院的无家可归者和非无家可归者之间的护理和死亡率模式是否存在差异？结果 在这项横断面研究中，2010 年至 2015 年间，纽约州、马萨诸塞州和佛罗里达州有 24 890 名无家可归成年人因心血管疾病住院，以及 1 827 900 名无家可归成年人因心血管疾病住院，结果显示，与非无家可归成年人相比，因急性心肌梗塞住院的无家可归者接受冠状动脉造影、经皮冠状动脉介入治疗和冠状动脉搭桥手术的可能性明显较低，并且死亡率更高。 ST 段抬高型心肌梗死。因心脏骤停或中风住院的无家可归者接受的程序护理也较少，死亡率也较高。含义 需要采取公共卫生和政策措施来支持照顾无家可归者的医院，减少医院护理方面的差异，并改善该人群的健康状况。
Importance Cardiovascular disease is a major cause of death among homeless adults, with mortality rates that are substantially higher than in the general population. It is unknown whether differences in hospitalization-related care contribute to these disparities in cardiovascular outcomes. Objective To evaluate differences in intensity of care and mortality between homeless and nonhomeless individuals hospitalized for cardiovascular conditions (ie, acute myocardial infarction, stroke, cardiac arrest, or heart failure). Design, Setting, and Participants This retrospective cross-sectional study included all hospitalizations for cardiovascular conditions among homeless adults (n = 24 890) and nonhomeless adults (n = 1 827 900) 18 years or older in New York, Massachusetts, and Florida from January 1, 2010, to September 30, 2015. Statistical analysis was performed from February 6 to July 16, 2019. Main Outcomes and Measures Risk-standardized diagnostic and therapeutic procedure rates and in-hospital mortality rates. Results Of the 1 852 790 total hospitalizations for cardiovascular conditions across 525 hospitals, 24 890 occurred among patients who were homeless (11 452 women and 13 438 men; mean [SD] age, 65.1 [14.8] years) and 1 827 900 occurred among patients who were not homeless (850 660 women and 977 240 men; mean [SD] age, 72.1 [14.6] years). Most hospitalizations among homeless individuals were primarily concentrated among 11 hospitals. Homeless adults were more likely than nonhomeless adults to be black (38.6% vs 15.6%) and insured by Medicaid (49.3% vs 8.5%). After accounting for differences in demographics (age, sex, and race/ethnicity), insurance payer, and clinical comorbidities, homeless adults hospitalized for acute myocardial infarction were less likely to undergo coronary angiography compared with nonhomeless adults (39.5% vs 70.9%; P < .001), percutaneous coronary intervention (24.8% vs 47.4%; P < .001), and coronary artery bypass graft (2.5% vs 7.0%; P < .001). Among adults hospitalized with stroke, those who were homeless were less likely than nonhomeless individuals to undergo cerebral angiography (2.9% vs 9.5%; P < .001) but were as likely to receive thrombolytic therapy (4.8% vs 5.2%; P = .28). In the cardiac arrest cohort, homeless adults were less likely than nonhomeless adults to undergo coronary angiography (10.1% vs 17.6%; P < .001) and percutaneous coronary intervention (0.0% vs 4.7%; P < .001). Risk-standardized mortality was higher for homeless persons with ST-elevation myocardial infarction compared with nonhomeless persons (8.3% vs 6.2%; P = .04). Mortality rates were also higher for homeless persons than for nonhomeless persons hospitalized with stroke (8.9% vs 6.3%; P < .001) or cardiac arrest (76.1% vs 57.4%; P < .001) but did not differ for heart failure (1.6% vs 1.6%; P = .83). Conclusions and Relevance There are significant disparities in in-hospital care and mortality between homeless and nonhomeless adults with cardiovascular conditions. There is a need for public health and policy efforts to support hospitals that care for homeless persons to reduce disparities in hospital-based care and improve health outcomes for this population.This cross-sectional study evaluates differences in intensity of care and mortality between homeless and nonhomeless individuals hospitalized for acute myocardial infarction, stroke, cardiac arrest, or heart failure.Question Do patterns of care and mortality differ between homeless and nonhomeless adults hospitalized for acute cardiovascular conditions? Findings In this cross-sectional study of 24 890 hospitalizations for cardiovascular conditions among homeless adults and 1 827 900 hospitalizations for cardiovascular conditions among nonhomeless adults in New York, Massachusetts, and Florida between 2010 and 2015, homeless individuals hospitalized with acute myocardial infarction were significantly less likely to undergo coronary angiography, percutaneous coronary intervention, and coronary artery bypass graft surgery compared with nonhomeless adults and had higher mortality rates for ST-elevation myocardial infarction. Homeless persons hospitalized for cardiac arrest or stroke also received less procedural care and had higher mortality rates. Meaning There is a need for public health and policy efforts to support hospitals that care for homeless persons, to reduce disparities in hospital-based care, and to improve health outcomes for this population.