Neuman Mark D, Wirtalla Christopher, Werner Rachel M
Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia2Leonard Davis Institute of Health Economics, University of Pennsylvania.
Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania.
JAMA. 2014 Oct 15;312(15):1542-51. doi: 10.1001/jama.2014.13513.
Hospital readmissions are common, costly, and potentially preventable. Little is known about the association between available skilled nursing facility (SNF) performance measures and the risk of hospital readmission.
To measure the association between SNF performance measures and hospital readmissions among Medicare beneficiaries receiving postacute care at SNFs in the United States.
Using national Medicare data on fee-for-service Medicare beneficiaries discharged to a SNF after an acute care hospitalization between September 1, 2009, and August 31, 2010, we examined the association between SNF performance on publicly available metrics (SNF staffing intensity, health deficiencies identified through site inspections, and the percentages of SNF patients with delirium, moderate to severe pain, and new or worsening pressure ulcers) and the risk of readmission or death 30 days after discharge to a SNF. Adjusted analyses controlled for patient case mix, SNF facility factors, and the discharging hospital.
Readmission to an acute care hospital or death within 30 days of the index hospital discharge.
Of 1,530,824 patients discharged, 357,752 (23.3%; 99% CI, 23.3%-23.5%) were readmitted or died within 30 days; 72,472 died within 30 days (4.7%; 99% CI, 4.7%-4.8%), and 321,709 were readmitted (21.0%; 99% CI, 20.9%-21.1%). The unadjusted risk of readmission or death was lower at SNFs with better staffing ratings. SNFs ranked lowest (19.2% of all SNFs) had a 30-day risk of readmission or death of 25.5% (99% CI, 25.3%-25.8%) vs 19.8% (99% CI, 19.5%-20.1%) among those ranked highest. SNFs with better facility inspection ratings also had a lower risk of readmission or death. SNFs ranked lowest (20.1% of all SNFs) had a risk of 24.9% (99% CI, 24.7%-25.1%) vs 21.5% (99% CI, 21.2%-21.7%) among those ranked highest . Adjustment for patient factors, SNF facility factors, and the discharging hospital attenuated these associations; we observed small differences in the adjusted risk of readmission or death according to SNF facility inspection ratings (lowest vs highest rating: 23.7%; 99% CI: 23.7%, 23.7%; vs 23.0%; 99% CI: 23.0%, 23.1%). Other measures did not predict clinically meaningful differences in the adjusted risk of readmission or death.
Among fee-for-service Medicare beneficiaries discharged to a SNF after an acute care hospitalization, available performance measures were not consistently associated with differences in the adjusted risk of readmission or death.
医院再入院情况常见、成本高昂且有可能预防。关于现有熟练护理设施（SNF）绩效指标与医院再入院风险之间的关联，人们了解甚少。
衡量美国SNF中接受急性后护理的医疗保险受益人的SNF绩效指标与医院再入院之间的关联。
利用2009年9月1日至2010年8月31日期间急性护理住院后被转至SNF的按服务收费医疗保险受益人的全国医疗保险数据，我们研究了SNF在公开可用指标（SNF人员配备强度、通过现场检查发现的健康缺陷，以及出现谵妄、中度至重度疼痛和新发或恶化压疮的SNF患者百分比）方面的绩效与转至SNF后30天内再入院或死亡风险之间的关联。调整后的分析对患者病例组合、SNF设施因素和转出医院进行了控制。
在首次出院后30天内再次入住急性护理医院或死亡。
在1,530,824名出院患者中，357,752名（23.3%；99%CI，23.3%-23.5%）在30天内再次入院或死亡；72,472名在30天内死亡（4.7%；99%CI，4.7%-4.8%），321,709名再次入院（21.0%；99%CI，20.9%-\(21.1\%\)）。人员配备评级较好的SNF中，未经调整的再入院或死亡风险较低。排名最低的SNF（占所有SNF的19.2%）30天再入院或死亡风险为25.5%（99%CI，25.3%-25.8%），而排名最高的SNF中这一风险为19.8%（99%CI，19.5%-20.1%）。设施检查评级较好的SNF再入院或死亡风险也较低。排名最低的SNF（占所有SNF的20.1%）风险为24.9%（99%CI，24.7%-25.1%），而排名最高的SNF中这一风险为21.5%（99%CI，21.2%-21.7%）。对患者因素、SNF设施因素和转出医院进行调整后，这些关联减弱；根据SNF设施检查评级，我们观察到调整后的再入院或死亡风险存在微小差异（最低评级与最高评级：23.7%；99%CI：23.7%，23.7%；对比23.0%；99%CI：23.0%，23.1%）。其他指标并未预测出调整后的再入院或死亡风险存在具有临床意义的差异。
在急性护理住院后被转至SNF的按服务收费医疗保险受益人中，现有的绩效指标与调整后的再入院或死亡风险差异之间并无一致关联。
