重症监护病房远程医疗项目对综合医疗体系中患者结局的影响。

Impact of an intensive care unit telemedicine program on patient outcomes in an integrated health care system.

机构信息

Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa2Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa Hospitals a.

Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa3Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City.

出版信息

JAMA Intern Med. 2014 Jul;174(7):1160-7. doi: 10.1001/jamainternmed.2014.1503.

DOI:10.1001/jamainternmed.2014.1503

PMID:24819673

Abstract

IMPORTANCE

Intensive care unit (ICU) telemedicine (TM) programs have been promoted as improving access to intensive care specialists and ultimately improving patient outcomes, but data on effectiveness are limited and conflicting.

OBJECTIVE

To examine the impact of ICU TM on mortality rates and length of stay (LOS) in an integrated health care system.

DESIGN, SETTING, AND PARTICIPANTS: Observational pre-post study of patients treated in 8 "intervention" ICUs (7 hospitals within the US Department of Veterans Affairs health care system) during 2011-2012 that implemented TM monitoring during the post-TM period as well as patients treated in concurrent control ICUs that did not implement an ICU TM program.

INTERVENTION

Implementation of ICU TM monitoring.

MAIN OUTCOMES AND MEASURES

Unadjusted and risk-adjusted ICU, in-hospital, and 30-day mortality rates and ICU and hospital LOS for patients who did or did not receive treatment in ICUs equipped with TM monitoring.

RESULTS

Our study included 3355 patients treated in our intervention ICUs (1708 in the pre-TM period and 1647 in the post-TM period) and 3584 treated in the control ICUs during the same period. Patient demographics and comorbid illnesses were similar in the intervention and control ICUs during the pre-TM and post-TM periods; however, predicted ICU mortality rates were modestly lower for admissions to the intervention ICUs compared with control ICUs in both the pre-TM (3.0% vs 3.6%; P = .02) and post-TM (2.8% vs 3.5%; P < .001) periods. Implementation of ICU TM was not associated with a significant decline in ICU, in-hospital, or 30-day mortality rates or LOS in unadjusted or adjusted analyses. For example, unadjusted ICU mortality in the pre-TM vs post-TM periods were 2.9% vs 2.8% (P = .89) for the intervention ICUs and 4.0% vs 3.4% (P = .31) for the control ICUs. Unadjusted 30-day mortality during the pre-TM vs post-TM periods were 7.7% vs 7.8% (P = .91) for the intervention ICUs and 12.0% vs 10.2% (P = .08) for the control ICUs. Evaluation of interaction terms comparing the magnitude of mortality rate change during the pre-TM and post-TM periods in the intervention and control ICUs failed to demonstrate a significant reduction in mortality rates or LOS.

CONCLUSIONS AND RELEVANCE

We found no evidence that the implementation of ICU TM significantly reduced mortality rates or LOS.

摘要

重要性

重症监护病房（ICU）远程医疗（TM）计划已被推广为改善重症监护专家的获取途径，并最终改善患者的预后，但有关有效性的数据有限且相互矛盾。

目的

在一个综合医疗保健系统中，研究 ICU TM 对死亡率和住院时间（LOS）的影响。

设计、地点和参与者：这是一项在 2011-2012 年期间于美国退伍军人事务部医疗保健系统内的 7 家医院的 8 个“干预”ICU 中进行的观察性前后研究，这些 ICU 在 TM 监测后的时期实施了 TM 监测，以及同时在没有实施 ICU TM 计划的对照 ICU 中接受治疗的患者。

干预措施

实施 ICU TM 监测。

主要结果和措施

在配备 TM 监测的 ICU 中接受或未接受治疗的患者的未调整和风险调整后的 ICU、院内和 30 天死亡率以及 ICU 和住院 LOS。

结果

我们的研究包括在干预 ICU 中接受治疗的 3355 名患者（TM 前时期的 1708 名和 TM 后时期的 1647 名）和同期在对照 ICU 中接受治疗的 3584 名患者。在 TM 前和 TM 后时期，干预和对照 ICU 中的患者人口统计学和合并症相似；然而，与对照 ICU 相比，干预 ICU 的 ICU 死亡率预测值在 TM 前（3.0%比 3.6%；P=0.02）和 TM 后（2.8%比 3.5%；P<0.001）时期均略低。在未调整和调整分析中，ICU TM 的实施与 ICU、院内或 30 天死亡率或 LOS 的显著下降均无关。例如，TM 前和 TM 后时期干预 ICU 的 ICU 死亡率分别为 2.9%和 2.8%（P=0.89），对照 ICU 分别为 4.0%和 3.4%（P=0.31）。TM 前和 TM 后时期干预 ICU 的 30 天死亡率分别为 7.7%和 7.8%（P=0.91），对照 ICU 分别为 12.0%和 10.2%（P=0.08）。比较干预和对照 ICU 中 TM 前和 TM 后时期死亡率变化幅度的交互作用项的评估未能显示死亡率或 LOS 有显著降低。