Englander Honora, Michaels Leann, Chan Benjamin, Kansagara Devan
Department of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, BTE 119, Portland, OR, 97239, USA,
J Gen Intern Med. 2014 Nov;29(11):1460-7. doi: 10.1007/s11606-014-2903-0. Epub 2014 Jun 10.
Despite growing emphasis on transitional care to reduce costs and improve quality, few studies have examined transitional care improvements in socioeconomically disadvantaged adults. It is important to consider these patients separately as many are high-utilizers, have different needs, and may have different responses to interventions.
To evaluate the impact of a multicomponent transitional care improvement program on 30-day readmissions, emergency department (ED) use, transitional care quality, and mortality.
Clustered randomized controlled trial conducted at a single urban academic medical center in Portland, Oregon.
Three hundred eighty-two hospitalized low-income adults admitted to general medicine or cardiology who were uninsured or had public insurance.
Multicomponent intervention including (1) transitional nurse coaching and education, including home visits for highest risk patients; (2) pharmacy care, including provision of 30 days of medications after discharge for those without prescription drug coverage; (3) post-hospital primary care linkages; (4) systems integration and continuous quality improvement.
Primary outcomes included 30-day inpatient readmission and ED use. Readmission data were obtained using state-wide administrative data for all participants (insured and uninsured). Secondary outcomes included quality (3-item Care Transitions Measure) and mortality. Research staff administering questionnaires and assessing outcomes were blinded.
There was no significant difference in 30-day readmission between C-TraIn (30/209, 14.4 %) and control patients (27/173, 16.1 %), p = 0.644, or in ED visits between C-TraIn (51/209, 24.4 %) and control (33/173, 19.6 %), p = 0.271. C-TraIn was associated with improved transitional care quality; 47.3 % (71/150) of C-TraIn patients reported a high quality transition compared to 30.3 % (36/119) control patients, odds ratio 2.17 (95 % CI 1.30-3.64). Zero C-TraIn patients died in the 30-day post-discharge period compared with five in the control group (unadjusted p = 0.02).
C-TraIn did not reduce 30-day inpatient readmissions or ED use; however, it improved transitional care quality.
尽管越来越强调过渡性护理以降低成本和提高质量，但很少有研究考察社会经济弱势成年人的过渡性护理改善情况。将这些患者单独考虑很重要，因为他们中许多人是高医疗资源使用者，有不同的需求，对干预措施的反应可能也不同。
评估一项多组分过渡性护理改善项目对30天再入院率、急诊科使用情况、过渡性护理质量和死亡率的影响。
在俄勒冈州波特兰市的一家城市学术医疗中心进行的整群随机对照试验。
382名入住普通内科或心内科的低收入住院成年人，他们未参保或参加了公共保险。
多组分干预，包括（1）过渡性护士指导与教育，包括对最高风险患者进行家访；（2）药学护理，包括为没有处方药保险的患者出院后提供30天的药物；（3）出院后初级保健联系；（4）系统整合与持续质量改进。
主要结局包括30天内再次住院和急诊科使用情况。使用全州范围内所有参与者（参保和未参保）的行政数据获取再入院数据。次要结局包括质量（3项护理过渡指标）和死亡率。发放问卷和评估结局的研究人员对分组情况不知情。
C-TraIn组（30/209，14.4%）和对照组患者（27/173，16.1%）的30天再入院率无显著差异，p = 0.644；C-TraIn组（51/209，24.4%）和对照组（33/173，19.6%）的急诊科就诊率也无显著差异，p = 0.271。C-TraIn与改善过渡性护理质量相关；47.3%（71/150）的C-TraIn组患者报告过渡质量高，而对照组患者为30.3%（36/119），比值比为2.17（95%可信区间1.30 - 3.64）。C-TraIn组在出院后30天内无患者死亡，而对照组有5例死亡（未调整p = 0.02）。
C-TraIn未降低30天内再次住院率或急诊科就诊率；然而，它改善了过渡性护理质量。
