Stearns S C
Department of Health Policy and Administration, School of Public Health, University of North Carolina, Chapel Hill 27599-7400.
Health Serv Res. 1991 Apr;26(1):27-51.
Although implementation of the Medicare prospective payment system has been accompanied by significant decreases in hospital length of stay, the early discharge of some patients may lead to worse health outcomes, particularly if sufficient aftercare services following hospitalization are not available. This article develops an empirical model of the relationship between the choice of length of stay and patient outcome. The model incorporates information on the severity of a patient's medical condition known by the physician who chooses length of stay for a patient but generally not known by a researcher interested in the factors that affect length of stay and health outcome. Joint estimation of equations for length of stay and health outcome controls for unmeasured aspects of case severity that affect both variables. The ratio of nursing home beds to Medicare enrollees in the county is included as an exogenous variable in both equations to assess whether variation in nursing home bed availability is correlated with length of stay or health outcome. The model is estimated using billing data for Medicare patients admitted with congestive heart failure to New Jersey hospitals during 1982 and 1983. Two measures of outcome are used: (1) a discrete measure of survival time following admission, and (2) a categorical measure of whether or not the patient was discharged dead or died within six months after discharge. Empirical results show no evidence that longer lengths of stay for congestive heart failure patients lead to lower postadmission mortality. However, greater availability of nursing home beds may reduce length of stay and may shift the provision of terminal care away from a hospital setting. Therefore, policies to expand the nursing home bed supply may enable further decreases in hospital length of stay without deleterious effect on patient outcome.
尽管医疗保险预付费系统的实施伴随着住院时间的显著缩短，但部分患者过早出院可能导致更差的健康结局，尤其是在住院后没有足够的后续护理服务的情况下。本文构建了一个关于住院时间选择与患者结局之间关系的实证模型。该模型纳入了医生所知晓的患者病情严重程度信息，医生会为患者选择住院时间，但对影响住院时间和健康结局因素感兴趣的研究人员通常并不知晓这些信息。对住院时间和健康结局方程进行联合估计，以控制影响这两个变量的病例严重程度中无法测量的方面。两个方程均将县内疗养院床位与医疗保险参保人数的比率作为外生变量纳入，以评估疗养院床位可获得性的变化是否与住院时间或健康结局相关。该模型使用1982年和1983年因充血性心力衰竭入住新泽西州医院的医疗保险患者的计费数据进行估计。使用了两种结局衡量指标：（1）入院后生存时间的离散衡量指标，以及（2）患者出院时是否死亡或出院后六个月内是否死亡的分类衡量指标。实证结果表明，没有证据表明充血性心力衰竭患者住院时间延长会导致入院后死亡率降低。然而，更多的疗养院床位供应可能会缩短住院时间，并可能将临终护理的提供从医院环境转移出去。因此，扩大疗养院床位供应的政策可能会在不对患者结局产生有害影响的情况下，进一步缩短住院时间。
