Income and Geographic Disparities in in‐Hospital Mortality Following Cardiovascular Procedures: Evidence From the National Inpatient Sample, 2016–2022
本研究利用2016-2022年全国住院患者数据，分析收入与地理位置对心血管手术后院内死亡率的影响，发现低收入患者死亡率更高，且医院间差异仅解释部分不平等，提示需同时关注社会因素和医院内部流程。
OBJECTIVE: To examine whether income- and geography-related disparities in in-hospital mortality after major cardiovascular procedures arise from differences in patient acuity, hospital characteristics, or inequities within hospitals. STUDY SETTING AND DESIGN: This observational study analyzed national data on eight major cardiovascular procedures performed between 2016 and 2022. We used multivariable logistic regression with progressive adjustment for demographics, clinical severity (All Patient Refined Diagnosis Related Groups [APR-DRG] risk and severity scores), and hospital characteristics. DATA SOURCES AND ANALYTIC SAMPLE: We analyzed secondary data from the National Inpatient Sample including 1,120,235 discharges (weighted N = 5,906,795) representing adults undergoing percutaneous coronary intervention, coronary artery bypass grafting, carotid endarterectomy/stenting, surgical valve replacement, transcatheter valve procedures, non-carotid endarterectomy, aneurysm repair, or peripheral bypass. Patient income was proxied using ZIP code-level median household income quartiles. Geographic location was classified as large metropolitan (≥ 1 million population), smaller metropolitan (50,000-999,999), or non-metropolitan. PRINCIPAL FINDINGS: Lowest-income patients presented with mean APR-DRG risk scores 0.15-0.25 points higher than highest-income patients. After full adjustment with hospital fixed effects, in-hospital mortality was 0.67% points higher (95% CI: 0.08-1.26) among lowest-income patients. Geographic patterns were complex: after adjusting for hospital characteristics, non-metropolitan location was associated with 0.48% points higher mortality, though this was not statistically significant (95% CI: -0.01 to 0.97), and smaller metropolitan areas with 1.03% points higher mortality (95% CI: 0.30-1.76). Between-hospital differences explained 11.6% of mortality variance. CONCLUSIONS: Socioeconomic and geographic disparities in mortality following major cardiovascular procedures persist after adjustment for clinical and hospital factors. These disparities remain, with slightly larger point estimates, in within-hospital analyses, suggesting that hospital-level differences alone do not account for observed inequities. Interventions should address both social determinants and intra-hospital inequities. Multilevel interventions targeting both social determinants and within-hospital processes may be needed.