Phillips Christopher O, Wright Scott M, Kern David E, Singa Ramesh M, Shepperd Sasha, Rubin Haya R
Quality of Care Research and General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Md, USA.
JAMA. 2004 Mar 17;291(11):1358-67. doi: 10.1001/jama.291.11.1358.
Comprehensive discharge planning plus postdischarge support may reduce readmission rates for older patients with congestive heart failure (CHF).
To evaluate the effect of comprehensive discharge planning plus postdischarge support on the rate of readmission in patients with CHF, all-cause mortality, length of stay (LOS), quality of life (QOL), and medical costs.
We searched MEDLINE (1966 to October 2003), the Cochrane Clinical Trials Register (all years), Social Science Citation Index (1992 to October 2003), and other databases for studies that described such an intervention and evaluated its effect in patients with CHF. Where possible we also contacted lead investigators and experts in the field.
We selected English-language publications of randomized clinical trials that described interventions to modify hospital discharge for older patients with CHF (mean age > or =55 years), delineated clearly defined inpatient and outpatient components, compared efficacy with usual care, and reported readmission as the primary outcome.
Two authors independently reviewed each report, assigned quality scores, and extracted data for primary and secondary outcomes in an unblinded standardized manner.
Eighteen studies representing data from 8 countries randomized 3304 older inpatients with CHF to comprehensive discharge planning plus postdischarge support or usual care. During a pooled mean observation period of 8 months (range, 3-12 months), fewer intervention patients were readmitted compared with controls (555/1590 vs 741/1714, number needed to treat = 12; relative risk [RR], 0.75; 95% confidence interval [CI], 0.64-0.88). Analysis of studies reporting secondary outcomes found a trend toward lower all-cause mortality for patients assigned to an intervention compared with usual care (RR, 0.87; 95% CI, 0.73-1.03; n = 14 studies), similar initial LOS (mean [SE]: 8.4 [2.5] vs 8.5 [2.2] days, P =.60; n = 10), greater percentage improvement in QOL scores compared with baseline scores (25.7% [95% CI, 11.0%-40.4%] vs 13.5% [95% CI, 5.1%-22.0%]; n = 6, P =.01), and similar or lower charges for medical care per patient per month for the initial hospital stay, administering the intervention, outpatient care, and readmission (-359 dollars [95% CI, -763 dollars to 45 dollars]; n = 4, P =.10 for non-US trials and -536 dollars [95% CI, -956 dollars to -115 dollars]; n = 4, P =.03, for US trials).
Comprehensive discharge planning plus postdischarge support for older patients with CHF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.
综合出院计划及出院后支持可能降低老年充血性心力衰竭（CHF）患者的再入院率。
评估综合出院计划及出院后支持对CHF患者再入院率、全因死亡率、住院时间（LOS）、生活质量（QOL）及医疗费用的影响。
我们检索了MEDLINE（1966年至2003年10月）、Cochrane临床试验注册库（所有年份）、社会科学引文索引（1992年至2003年10月）及其他数据库，以查找描述此类干预措施并评估其对CHF患者影响的研究。如有可能，我们还联系了该领域的主要研究者和专家。
我们选择了随机临床试验的英文出版物，这些试验描述了针对老年CHF患者（平均年龄≥55岁）调整出院安排的干预措施，明确界定了住院和门诊部分，将疗效与常规治疗进行了比较，并将再入院作为主要结局进行报告。
两位作者独立审查每份报告，分配质量评分，并以非盲标准化方式提取主要和次要结局的数据。
18项研究代表来自8个国家的数据，将3304例老年CHF住院患者随机分为综合出院计划及出院后支持组或常规治疗组。在汇总的平均观察期8个月（范围3 - 12个月）内，与对照组相比，干预组再入院的患者较少（555/1590 vs 741/1714，需治疗人数 = 12；相对危险度[RR]，0.75；95%置信区间[CI]，0.64 - 0.88）。对报告次要结局的研究进行分析发现，与常规治疗相比，接受干预的患者全因死亡率有降低趋势（RR，0.87；95% CI，0.73 - 1.03；n = 14项研究），初始住院时间相似（均值[标准误]：8.4[2.5]天 vs 8.5[2.2]天，P = 0.60；n = 10），与基线评分相比QOL评分改善百分比更高（25.7%[95% CI，11.0% - 40.4%] vs 13.5%[95% CI，5.1% - 22.0%]；n = 6，P = 0.01），并且初始住院、实施干预、门诊治疗及再入院的每位患者每月医疗费用相似或更低（-359美元[95% CI，-763美元至45美元]；n = 4，非美国试验P = 0.10，美国试验为-536美元[95% CI，-956美元至-115美元]；n = 4，P = 0.03）。
对老年CHF患者进行综合出院计划及出院后支持可显著降低再入院率，并可能改善生存和QOL等健康结局，且不增加费用。
