Stephens Caroline E, Sackett Nathan, Govindarajan Prasanthi, Lee Sei J
Department of Community Health Systems, University of California San Francisco, 2 Koret Way, #N531E, San Francisco, CA 94143-0608, USA.
BMC Geriatr. 2014 Mar 20;14:35. doi: 10.1186/1471-2318-14-35.
Numerous studies indicate that the use of feeding tubes (FT) in persons with advanced cognitive impairment (CI) does not improve clinical outcomes or survival, and results in higher rates of hospitalization and emergency department (ED) visits. It is not clear, however, whether such risk varies by resident level of CI and whether these ED visits and hospitalizations are potentially preventable. The objective of this study was to determine the rates of ED visits, hospitalizations and potentially preventable ambulatory care sensitive (ACS) ED visits and ACS hospitalizations for long-stay NH residents with FTs at differing levels of CI.
We linked Centers for Medicare and Medicaid Services inpatient & outpatient administrative claims and beneficiary eligibility data with Minimum Data Set (MDS) resident assessment data for nursing home residents with feeding tubes in a 5% random sample of Medicare beneficiaries residing in US nursing facilities in 2006 (n = 3479). Severity of CI was measured using the Cognitive Performance Scale (CPS) and categorized into 4 groups: None/Mild (CPS = 0-1, MMSE = 22-25), Moderate (CPS = 2-3, MMSE = 15-19), Severe (CPS = 4-5, MMSE = 5-7) and Very Severe (CPS = 6, MMSE = 0-4). ED visits, hospitalizations, ACS ED visits and ACS hospitalizations were ascertained from inpatient and outpatient administrative claims. We estimated the risk ratio of each outcome by CI level using over-dispersed Poisson models accounting for potential confounding factors.
Twenty-nine percent of our cohort was considered "comatose" and "without any discernible consciousness", suggesting that over 20,000 NH residents in the US with feeding tubes are non-interactive. Approximately 25% of NH residents with FTs required an ED visit or hospitalization, with 44% of hospitalizations and 24% of ED visits being potentially preventable or for an ACS condition. Severity of CI had a significant effect on rates of ACS ED visits, but little effect on ACS hospitalizations.
ED visits and hospitalizations are common in cognitively impaired tube-fed nursing home residents and a substantial proportion of ED visits and hospitalizations are potentially preventable due to ACS conditions.
大量研究表明，在晚期认知障碍（CI）患者中使用饲管（FT）并不能改善临床结局或提高生存率，反而会导致更高的住院率和急诊就诊率。然而，尚不清楚这种风险是否因CI的严重程度而异，以及这些急诊就诊和住院是否有可能预防。本研究的目的是确定不同CI水平的长期护理机构（NH）中使用饲管的居民的急诊就诊率、住院率以及潜在可预防的非卧床护理敏感（ACS）急诊就诊率和ACS住院率。
我们将医疗保险和医疗补助服务中心的住院和门诊管理索赔数据以及受益人资格数据与2006年居住在美国护理机构的5%随机抽样医疗保险受益人的疗养院居民的最低数据集（MDS）居民评估数据相链接（n = 3479）。使用认知表现量表（CPS）测量CI的严重程度，并将其分为4组：无/轻度（CPS = 0 - 1，简易精神状态检查表[MMSE] = 22 - 25）、中度（CPS = 2 - 3，MMSE = 15 - 19）、重度（CPS = 4 - 5，MMSE = 5 - 7）和极重度（CPS = 6，MMSE = 0 - 4）。从住院和门诊管理索赔中确定急诊就诊、住院、ACS急诊就诊和ACS住院情况。我们使用考虑潜在混杂因素的过度分散泊松模型，按CI水平估计每个结局的风险比。
我们队列中的29%被认为“昏迷”且“没有任何可察觉的意识”，这表明美国超过20,000名使用饲管的NH居民没有互动能力。约25%使用饲管的NH居民需要急诊就诊或住院，其中44%的住院和24%的急诊就诊可能是可预防的或由ACS疾病导致的。CI的严重程度对ACS急诊就诊率有显著影响，但对ACS住院率影响较小。
认知障碍的鼻饲疗养院居民中急诊就诊和住院很常见，并且由于ACS疾病，相当一部分急诊就诊和住院是有可能预防的。
