重症监护病房远程医疗与危重症死亡率：一项全国性疗效研究。
ICU Telemedicine and Critical Care Mortality: A National Effectiveness Study.
作者信息
Kahn Jeremy M, Le Tri Q, Barnato Amber E, Hravnak Marilyn, Kuza Courtney C, Pike Francis, Angus Derek C
机构信息
*Department of Critical Care Medicine, CRISMA Center, University of Pittsburgh School of Medicine †Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health ‡Division of General Internal Medicine, University of Pittsburgh School of Medicine §Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing ∥Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA.
出版信息
Med Care. 2016 Mar;54(3):319-25. doi: 10.1097/MLR.0000000000000485.
BACKGROUND
Intensive care unit (ICU) telemedicine is an increasingly common strategy for improving the outcome of critical care, but its overall impact is uncertain.
OBJECTIVES
To determine the effectiveness of ICU telemedicine in a national sample of hospitals and quantify variation in effectiveness across hospitals.
RESEARCH DESIGN
We performed a multicenter retrospective case-control study using 2001-2010 Medicare claims data linked to a national survey identifying US hospitals adopting ICU telemedicine. We matched each adopting hospital (cases) to up to 3 nonadopting hospitals (controls) based on size, case-mix, and geographic proximity during the year of adoption. Using ICU admissions from 2 years before and after the adoption date, we compared outcomes between case and control hospitals using a difference-in-differences approach.
RESULTS
A total of 132 adopting case hospitals were matched to 389 similar nonadopting control hospitals. The preadoption and postadoption unadjusted 90-day mortality was similar in both case hospitals (24.0% vs. 24.3%, P=0.07) and control hospitals (23.5% vs. 23.7%, P<0.01). In the difference-in-differences analysis, ICU telemedicine adoption was associated with a small relative reduction in 90-day mortality (ratio of odds ratios=0.96; 95% CI, 0.95-0.98; P<0.001). However, there was wide variation in the ICU telemedicine effect across individual hospitals (median ratio of odds ratios=1.01; interquartile range, 0.85-1.12; range, 0.45-2.54). Only 16 case hospitals (12.2%) experienced statistically significant mortality reductions postadoption. Hospitals with a significant mortality reduction were more likely to have large annual admission volumes (P<0.001) and be located in urban areas (P=0.04) compared with other hospitals.
CONCLUSIONS
Although ICU telemedicine adoption resulted in a small relative overall mortality reduction, there was heterogeneity in effect across adopting hospitals, with large-volume urban hospitals experiencing the greatest mortality reductions.
背景
重症监护病房（ICU）远程医疗是改善重症监护结果的一种日益常见的策略，但其总体影响尚不确定。
目的
确定ICU远程医疗在全国医院样本中的有效性，并量化各医院有效性的差异。
研究设计
我们使用2001 - 2010年医疗保险索赔数据进行了一项多中心回顾性病例对照研究，该数据与一项全国性调查相关联，该调查确定了采用ICU远程医疗的美国医院。在采用ICU远程医疗的年份，我们根据规模、病例组合和地理位置，将每家采用医院（病例）与多达3家未采用医院（对照）进行匹配。利用采用日期前后2年的ICU入院数据，我们采用差异中的差异方法比较了病例医院和对照医院的结果。
结果
总共132家采用病例医院与389家类似的未采用对照医院进行了匹配。病例医院（24.0%对24.3%，P = 0.07）和对照医院（23.5%对23.7%，P < 0.01）在采用前和采用后的未经调整的90天死亡率相似。在差异中的差异分析中，采用ICU远程医疗与90天死亡率的相对小幅降低相关（优势比比值 = 0.96；95%置信区间，0.95 - 0.98；P < 0.001）。然而，各医院之间ICU远程医疗的效果差异很大（优势比比值中位数 = 1.01；四分位间距，0.85 - 1.12；范围，0.45 - 2.54）。只有16家病例医院（12.2%）在采用后经历了统计学上显著的死亡率降低。与其他医院相比，死亡率显著降低的医院更有可能年入院量大（P < 0.001）且位于城市地区（P = 0.04）。
结论
虽然采用ICU远程医疗导致总体死亡率相对小幅降低，但各采用医院的效果存在异质性，年入院量大的城市医院死亡率降低幅度最大。
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