Abdelsattar Zaid M, Gonzalez Andrew A, Hendren Samantha, Regenbogen Scott E, Wong Sandra L
*Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI†Department of Surgery, Mayo Clinic, Rochester, MN‡Department of Surgery, University of Illinois Chicago, Chicago, IL.
Ann Surg. 2016 Aug;264(2):291-6. doi: 10.1097/SLA.0000000000001498.
The aim of the study was to identify hospital characteristics associated with variation in patient disposition after emergent surgery.
Colon resections in elderly patients are often done in emergent settings. Although these operations are known to be riskier, there are limited data regarding postoperative discharge destination.
We evaluated Medicare beneficiaries who underwent emergent colectomy between 2008 and 2010. Using hierarchical logistic regression, we estimated patient and hospital-level risk-adjusted rates of nonhome discharges. Hospitals were stratified into quintiles based on their nonhome discharge rates. Generalized linear models were used to identify hospital structural characteristics associated with nonhome discharges (comparing discharge to skilled nursing facilities vs home with/without home health services).
Of the 122,604 patients surviving to discharge after emergent colectomy at 3012 hospitals, 46.7% were discharged to a nonhome destination. There was a wide variation in risk and reliability-adjusted nonhome discharge rates across hospitals (15% to 80%). Patients at hospitals in the highest quintile of nonhome discharge rates were more likely to have longer hospitalizations (15.1 vs 13.2; P < 0.001) and more complications (43.2% vs 34%; P < 0.001). On multivariable analysis, only hospital ownership of a skilled nursing facility (P < 0.001), teaching status (P = 0.025), and low nurse-to-patient ratios (P = 0.002) were associated with nonhome discharges.
Nearly half of Medicare beneficiaries are discharged to a nonhome destination after emergent colectomy. Hospital ownership of a skilled nursing facility and low nurse-to-patient ratios are highly associated with nonhome discharges. This may signify the underlying financial incentives to preferentially utilize postacute care facilities under the traditional fee-for-service payment model.
本研究旨在确定与急诊手术后患者处置差异相关的医院特征。
老年患者的结肠切除术常在急诊情况下进行。尽管已知这些手术风险更高，但关于术后出院目的地的数据有限。
我们评估了2008年至2010年间接受急诊结肠切除术的医疗保险受益人。使用分层逻辑回归，我们估计了患者和医院层面经风险调整的非家庭出院率。根据非家庭出院率将医院分为五等份。使用广义线性模型确定与非家庭出院相关的医院结构特征（比较出院至专业护理机构与有/无家庭健康服务的家庭）。
在3012家医院接受急诊结肠切除术后存活至出院的122,604名患者中，46.7%出院至非家庭目的地。各医院经风险和可靠性调整的非家庭出院率差异很大（15%至80%）。非家庭出院率最高五分之一的医院的患者住院时间更长（15.1天对13.2天；P<0.001）且并发症更多（43.2%对34%；P<0.001）。多变量分析显示，只有拥有专业护理机构的医院所有权（P<0.001）、教学地位（P=0.025）和低护士与患者比例（P=0.002）与非家庭出院相关。
近一半的医疗保险受益人在急诊结肠切除术后出院至非家庭目的地。拥有专业护理机构的医院所有权和低护士与患者比例与非家庭出院高度相关。这可能表明在传统的按服务收费支付模式下，优先利用急性后期护理机构存在潜在的经济激励因素。
