接受重症监护治疗的 Medicare 受益人的三年预后。

Three-year outcomes for Medicare beneficiaries who survive intensive care.

机构信息

Department of Anesthesiology, Columbia University, 622 W 168th St, PH-527D, New York, NY 10032, USA.

出版信息

JAMA. 2010 Mar 3;303(9):849-56. doi: 10.1001/jama.2010.216.

DOI:10.1001/jama.2010.216

PMID:20197531

Abstract

CONTEXT

Although hospital mortality has decreased over time in the United States for patients who receive intensive care, little is known about subsequent outcomes for those discharged alive.

OBJECTIVE

To assess 3-year outcomes for Medicare beneficiaries who survive intensive care.

DESIGN, SETTING, AND PATIENTS: A matched, retrospective cohort study was conducted using a 5% sample of Medicare beneficiaries older than 65 years. A random half of all patients were selected who received intensive care and survived to hospital discharge in 2003 with 3-year follow-up through 2006. From the other half of the sample, 2 matched control groups were generated: hospitalized patients who survived to discharge (hospital controls) and the general population (general controls), individually matched on age, sex, race, and whether they had surgery (for hospital controls).

MAIN OUTCOME MEASURE

Three-year mortality after hospital discharge.

RESULTS

There were 35,308 intensive care unit (ICU) patients who survived to hospital discharge. The ICU survivors had a higher 3-year mortality (39.5%; n = 13,950) than hospital controls (34.5%; n = 12,173) (adjusted hazard ratio [AHR], 1.07 [95% confidence interval {CI}, 1.04-1.10]; P < .001) and general controls (14.9%; n = 5266) (AHR, 2.39 [95% CI, 2.31-2.48]; P < .001). The ICU survivors who did not receive mechanical ventilation had minimal increased risk compared with hospital controls (3-year mortality, 38.3% [n = 12,716] vs 34.6% [n=11,470], respectively; AHR, 1.04 [95% CI, 1.02-1.07]). Those receiving mechanical ventilation had substantially increased mortality (57.6% [1234 ICU survivors] vs 32.8% [703 hospital controls]; AHR, 1.56 [95% CI, 1.40-1.73]), with risk concentrated in the 6 months after the quarter of hospital discharge (6-month mortality, 30.1% (n = 645) for those receiving mechanical ventilation vs 9.6% (n = 206) for hospital controls; AHR, 2.26 [95% CI, 1.90-2.69]). Discharge to a skilled care facility for ICU survivors (33.0%; n = 11,634) and hospital controls (26.4%; n = 9328) also was associated with high 6-month mortality (24.1% for ICU survivors and hospital controls discharged to a skilled care facility vs 7.5% for ICU survivors and hospital controls discharged home; AHR, 2.62 [95% CI, 2.50-2.74]; P < .001 for ICU survivors and hospital controls combined).

CONCLUSIONS

There is a large US population of elderly individuals who survived the ICU stay to hospital discharge but who have a high mortality over the subsequent years in excess of that seen in comparable controls. The risk is concentrated early after hospital discharge among those who require mechanical ventilation.

摘要

背景

尽管在美国，接受重症监护的患者的医院死亡率随着时间的推移而下降，但对于存活下来并出院的患者的后续结果知之甚少。

目的

评估在重症监护中存活下来的医疗保险受益人的 3 年结局。

设计、地点和患者：使用医疗保险受益人的 5%的样本进行了匹配的回顾性队列研究，年龄大于 65 岁。所有接受重症监护并在 2003 年存活至出院并在 2006 年进行 3 年随访的患者中随机抽取一半。从样本的另一半中，生成了 2 个匹配的对照组：存活至出院的住院患者（医院对照组）和一般人群（一般对照组），分别按年龄、性别、种族和是否接受手术进行匹配（对于医院对照组）。

主要观察指标

出院后 3 年的死亡率。

结果

共有 35308 名在重症监护病房（ICU）存活至出院的 ICU 患者。ICU 幸存者的 3 年死亡率（39.5%；n=13950）高于医院对照组（34.5%；n=12173）（调整后的危险比[HR]，1.07[95%置信区间{CI}，1.04-1.10]；P<0.001）和一般对照组（14.9%；n=5266）（HR，2.39[95%CI，2.31-2.48]；P<0.001）。与医院对照组相比，未接受机械通气的 ICU 幸存者的风险增加较小（3 年死亡率，38.3%[n=12716]与 34.6%[n=11470]，分别；HR，1.04[95%CI，1.02-1.07]）。接受机械通气的患者死亡率显著增加（57.6%[1234 名 ICU 幸存者]与 32.8%[703 名医院对照组]；HR，1.56[95%CI，1.40-1.73]），风险集中在出院后季度的 6 个月内（接受机械通气的患者 6 个月死亡率为 30.1%（n=645），而医院对照组为 9.6%（n=206）；HR，2.26[95%CI，1.90-2.69]）。对于 ICU 幸存者（33.0%；n=11634）和医院对照组（26.4%；n=9328）出院至康复护理机构的患者，6 个月死亡率也很高（ICU 幸存者和医院对照组出院至康复护理机构的患者为 24.1%，而 ICU 幸存者和医院对照组出院回家的患者为 7.5%；HR，2.62[95%CI，2.50-2.74]；P<0.001，ICU 幸存者和医院对照组合计）。