Colorado Foundation for Medical Care, Englewood, USA.
JAMA. 2013 Jan 23;309(4):381-91. doi: 10.1001/jama.2012.216607.
Medicare beneficiaries experience errors during transitions among care settings, yielding harms that include unnecessary rehospitalizations.
To evaluate whether implementation of improved care transitions for patients with Medicare fee-for-service (FFS) insurance is associated with reduced rehospitalizations and hospitalizations in geographic communities.
DESIGN, SETTING, AND PARTICIPANTS: Quality improvement initiative for care transitions by health care and social services personnel and Medicare Quality Improvement Organization staff in defined geographic areas, with monitoring by community-specific and aggregate control charts and evaluation with pre-post comparison of performance differences for 14 intervention communities and 50 comparison communities from before (2006-2008) and during (2009-2010) implementation. Intervention communities had between 22,070 and 90,843 Medicare FFS beneficiaries.
Quality Improvement Organizations facilitated community-wide quality improvement activities to implement evidence-based improvements in care transitions by community organizing, technical assistance, and monitoring of participation, implementation, effectiveness, and adverse effects.
The primary outcome measure was all-cause 30-day rehospitalizations per 1000 Medicare FFS beneficiaries; secondary outcome measures were all-cause hospitalizations per 1000 Medicare FFS beneficiaries and all-cause 30-day rehospitalizations as a percentage of hospital discharges.
The mean rate of 30-day all-cause rehospitalizations per 1000 beneficiaries per quarter was 15.21 in 2006-2008 and 14.34 in 2009-2010 in the 14 intervention communities and was 15.03 in 2006-2008 and 14.72 in 2009-2010 in the 50 comparison communities, with the pre-post between-group difference showing larger reductions in rehospitalizations in intervention communities (by 0.56/1000 per quarter; 95% CI, 0.05-1.07; P = .03). The mean rate of hospitalizations per 1000 beneficiaries per quarter was 82.27 in 2006-2008 and 77.54 in 2009-2010 in intervention communities and was 82.09 in 2006-2008 and 79.48 in 2009-2010 in comparison communities, with the pre-post between-group difference showing larger reductions in hospitalizations in intervention communities (by 2.12/1000 per quarter; 95% CI, 0.47-3.77; P = .01). Mean community-wide rates of rehospitalizations as a percentage of hospital discharges in the intervention communities were 18.97% in 2006-2008 and 18.91% in 2009-2010 and were 18.76% in 2006-2008 and 18.91% in 2009-2010 in the comparison communities, with no significant difference in the pre-post between-group differences (0.22%; 95% CI, -0.08% to 0.51%; P = .14). Process control charts signaled onset of improvement coincident with initiating intervention.
Among Medicare beneficiaries in intervention communities, compared with those in uninvolved communities, all-cause 30-day rehospitalization and all-cause hospitalization declined. However, there was no change in the rate of all-cause 30-day rehospitalizations as a percentage of hospital discharges.
重要性：医疗保险受益人在医疗环境过渡期间会出现错误，导致不必要的再次住院等危害。
目的：评估为医疗保险按服务收费（FFS）保险患者实施改善的护理过渡是否与减少再入院和地理社区的住院有关。
设计、地点和参与者：医疗保健和社会服务人员以及医疗保险质量改进组织工作人员的护理过渡质量改进举措，由特定社区和总体控制图进行监测，并通过比较实施前后 14 个干预社区和 50 个对照社区的绩效差异进行评估，比较社区包括 2006-2008 年（前）和 2009-2010 年（中）。干预社区有 22070 至 90843 名医疗保险 FFS 受益人。
干预措施：质量改进组织通过社区组织、技术援助和参与、实施、效果和不良影响的监测，促进社区范围内的质量改进活动，以实施护理过渡方面的循证改进。
主要结果测量：主要结果测量是每 1000 名医疗保险 FFS 受益人 30 天内所有原因的再住院率；次要结果测量是每 1000 名医疗保险 FFS 受益人的所有原因住院率和所有原因 30 天内再住院率作为出院率的百分比。
结果：在干预社区中，每季度每 1000 名受益人的 30 天内所有原因再住院率的平均值在 2006-2008 年为 15.21，在 2009-2010 年为 14.34，在 50 个对照社区中，2006-2008 年为 15.03，2009-2010 年为 14.72，组间前后差异显示干预社区的再住院率降低幅度更大（每季度减少 0.56/1000；95%置信区间，0.05-1.07；P =.03）。在干预社区中，每季度每 1000 名受益人的住院率的平均值在 2006-2008 年为 82.27，在 2009-2010 年为 77.54，在对照社区中，2006-2008 年为 82.09，在 2009-2010 年为 79.48，组间前后差异显示干预社区的住院率降低幅度更大（每季度减少 2.12/1000；95%置信区间，0.47-3.77；P =.01）。在干预社区中，社区范围内 30 天内再住院率作为出院率的百分比平均值在 2006-2008 年为 18.97%，在 2009-2010 年为 18.91%，在对照社区中，2006-2008 年为 18.76%，在 2009-2010 年为 18.91%，组间前后差异无统计学意义（0.22%；95%置信区间，-0.08%至 0.51%；P =.14）。过程控制图表明，在开始干预的同时，改进开始生效。
结论和相关性：在参与社区的医疗保险受益人中，与未参与社区相比，所有原因的 30 天内再住院率和所有原因的住院率均有所下降。然而，所有原因的 30 天内再住院率作为出院率的百分比并没有变化。
