Dharmarajan Kumar, Hsieh Angela F, Kulkarni Vivek T, Lin Zhenqiu, Ross Joseph S, Horwitz Leora I, Kim Nancy, Suter Lisa G, Lin Haiqun, Normand Sharon-Lise T, Krumholz Harlan M
Department of Internal Medicine, Columbia University Medical Center, NY, USA
Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA.
BMJ. 2015 Feb 5;350:h411. doi: 10.1136/bmj.h411.
To characterize the absolute risks for older patients of readmission to hospital and death in the year after hospitalization for heart failure, acute myocardial infarction, or pneumonia.
Retrospective cohort study.
4767 hospitals caring for Medicare fee for service beneficiaries in the United States, 2008-10.
More than 3 million Medicare fee for service beneficiaries, aged 65 years or more, surviving hospitalization for heart failure, acute myocardial infarction, or pneumonia.
Daily absolute risks of first readmission to hospital and death for one year after discharge. To illustrate risk trajectories, we identified the time required for risks of readmission to hospital and death to decline 50% from maximum values after discharge; the time required for risks to approach plateau periods of minimal day to day change, defined as 95% reductions in daily changes in risk from maximum daily declines after discharge; and the extent to which risks are higher among patients recently discharged from hospital compared with the general elderly population.
Within one year of hospital discharge, readmission to hospital and death, respectively, occurred following 67.4% and 35.8% of hospitalizations for heart failure, 49.9% and 25.1% for acute myocardial infarction, and 55.6% and 31.1% for pneumonia. Risk of first readmission had declined 50% by day 38 after hospitalization for heart failure, day 13 after hospitalization for acute myocardial infarction, and day 25 after hospitalization for pneumonia; risk of death declined 50% by day 11, 6, and 10, respectively. Daily change in risk of first readmission to hospital declined 95% by day 45, 38, and 45; daily change in risk of death declined 95% by day 21, 19, and 21. After hospitalization for heart failure, acute myocardial infarction, or pneumonia, the magnitude of the relative risk for hospital admission over the first 90 days was 8, 6, and 6 times greater than that of the general older population; the relative risk of death was 11, 8, and 10 times greater.
Risk declines slowly for older patients after hospitalization for heart failure, acute myocardial infarction, or pneumonia and is increased for months. Specific risk trajectories vary by discharge diagnosis and outcome. Patients should remain vigilant for deterioration in health for an extended time after discharge. Health providers can use knowledge of absolute risks and their changes over time to better align interventions designed to reduce adverse outcomes after discharge with the highest risk periods for patients.
描述老年患者因心力衰竭、急性心肌梗死或肺炎住院后一年内再次入院和死亡的绝对风险。
回顾性队列研究。
2008年至2010年美国4767家为医疗保险按服务付费受益人群提供服务的医院。
300多万医疗保险按服务付费受益人群，年龄在65岁及以上，因心力衰竭、急性心肌梗死或肺炎住院后存活。
出院后一年内首次再次入院和死亡的每日绝对风险。为了说明风险轨迹，我们确定了再次入院和死亡风险从出院后最大值下降50%所需的时间；风险接近日常变化最小的平稳期所需的时间，定义为风险每日变化从出院后最大每日下降幅度减少95%；以及与一般老年人群相比，近期出院患者的风险更高的程度。
在出院后一年内，心力衰竭住院患者中分别有67.4%和35.8%再次入院和死亡，急性心肌梗死住院患者中分别有49.9%和25.1%再次入院和死亡，肺炎住院患者中分别有55.6%和31.1%再次入院和死亡。心力衰竭住院后第38天、急性心肌梗死住院后第13天、肺炎住院后第25天，首次再次入院风险下降50%；死亡风险分别在第11天、第6天和第10天下降50%。首次再次入院风险的每日变化在第45天、第38天和第45天下降95%；死亡风险的每日变化在第21天、第19天和第21天下降95%。因心力衰竭、急性心肌梗死或肺炎住院后，前90天内再次入院的相对风险幅度分别是一般老年人群的8倍、6倍和6倍；死亡的相对风险分别是11倍、8倍和10倍。
老年患者因心力衰竭、急性心肌梗死或肺炎住院后，风险下降缓慢且持续数月。具体风险轨迹因出院诊断和结局而异。患者出院后应在较长时间内保持对健康恶化的警惕。医疗服务提供者可以利用绝对风险及其随时间变化的知识，使旨在降低出院后不良结局的干预措施与患者的最高风险期更好地匹配。
