Kane R L, Chen Q, Finch M, Blewett L, Burns R, Moskowitz M
University of Minnesota School of Public Health, Minneapolis 55455, USA.
Health Serv Res. 2000 Aug;35(3):615-61.
To estimate the differences in functional outcomes attributable to discharge to one of four different venues for post-hospital care for each of five different types of illness associated with post-hospital care: stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hip procedures, and hip fracture, and to estimate the costs and benefits associated with discharge to the type of care that was estimated to produce the greatest improvement.
STUDY SETTING/DATA SOURCES: Consecutive patients with any of the target diagnoses were enrolled from 52 hospitals in three cities. Data sources included interviews with patients or their proxies, medical record reviews, and the Medicare Automated Data Retrieval System.
A two-stage regression model looked first at the factors associated with discharge to each type of post-hospital care and then at the outcomes associated with each location. An instrumental variables technique was used to adjust for selection bias. A predictive model was created for each patient to estimate how that person would have fared had she or he been discharged to each type of care. The optimal discharge location was determined as that which produced the greatest improvement in function after adjusting for patients' baseline characteristics. The costs of discharge to the optimal type of care was based on the differences in mean costs for each location.
DATA COLLECTION/EXTRACTION METHODS: Data were collected from patients or their proxies at discharge from hospital and at three post-discharge follow-up times: six weeks, six months, and one year. In addition, the medical records for each participant were abstracted by trained abstractors, using a modification of the Medisgroups method, and Medicare data were summarized for the years before and after the hospitalization.
In general, patients discharged to nursing homes fared worst and those sent home with home health care or to rehabilitation did best. Because the cost of rehabilitation is high, greater use of home care could result in improved outcomes at modest or no additional cost.
Better decisions about where to discharge patients could improve the course of many patients. It is possible to save money by making wiser discharge planning decisions. Nursing homes are generally associated with poorer outcomes and higher costs than the other post-hospital care modalities.
评估因出院后护理场所不同(分为四种不同场所)而导致的功能结局差异,这四种场所针对与出院后护理相关的五种不同疾病类型:中风、慢性阻塞性肺疾病(COPD)、充血性心力衰竭(CHF)、髋关节手术以及髋部骨折;并评估出院至估计能带来最大改善的护理类型所产生的成本和效益。
研究背景/数据来源:从三个城市的52家医院连续纳入患有任何目标诊断疾病的患者。数据来源包括对患者或其代理人的访谈、病历审查以及医疗保险自动数据检索系统。
采用两阶段回归模型,首先研究与出院后每种护理类型相关的因素,然后研究与每个场所相关的结局。使用工具变量技术来调整选择偏倚。为每位患者创建一个预测模型,以估计如果该患者被转至每种护理类型其情况会如何。在调整患者基线特征后,将产生最大功能改善的场所确定为最佳出院地点。出院至最佳护理类型的成本基于每个场所平均成本的差异。
数据收集/提取方法:在患者出院时以及出院后的三个随访时间点(六周、六个月和一年)从患者或其代理人处收集数据。此外,由经过培训的提取人员使用改良的Medisgroups方法提取每位参与者的病历,并汇总住院前后年份的医疗保险数据。
总体而言,出院至养老院的患者情况最差,而那些接受家庭医疗护理或被送至康复机构的患者情况最佳。由于康复成本高昂,更多地使用家庭护理可能在适度增加成本或不增加额外成本的情况下改善结局。
关于患者出院地点的更好决策可以改善许多患者的病程。通过做出更明智的出院计划决策有可能节省资金。与其他出院后护理方式相比,养老院通常与较差的结局和更高的成本相关。