McAlister Finlay A, Youngson Erik, Kaul Padma
Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada
Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada.
J Am Heart Assoc. 2017 May 10;6(5):e004892. doi: 10.1161/JAHA.116.004892.
Up to one fifth of readmissions after a heart failure hospitalization occur at a different hospital. This negatively impacts information continuity, but whether site of readmission impacts subsequent outcomes is unclear.
Retrospective cohort study of all patients discharged with a primary diagnosis of heart failure in Canada between April 2004 and December 2013. We compared patients readmitted within 30 days to the original hospital versus a different hospital. Of the 217 039 heart failure patients (mean age, 76.8 years, 50.1% male), 39 368 (18.1%) were readmitted within 30 days-32 771 (83.2%) to the original hospital and 6597 (16.8%) to a different hospital (increasing over time from 15.6% in 2004 to 18.5% by 2013; for trend=0.001). Patients readmitted to different hospitals were younger and were more likely to be male, have a rural residence, a more-recent discharge year, an index hospitalization at a teaching hospital, and to be brought in by ambulance at the time of the readmission. Readmissions to the original hospital were substantially shorter (mean, 10.4 days [95% CI, 10.3-10.6] versus 11.6 days [95% CI, 11.3-12.0]; adjusted means, 11.0 versus 12.0; <0.0001) and had lower mortality (14.4% versus 15.0%; adjusted odds ratio, 0.89; 95% CI, 0.82-0.96) than readmissions to different hospitals.
Readmissions to a different hospital are becoming more frequent over time and are associated with longer stays and higher mortality rates than readmissions to the original hospital. Our findings provide further evidence that care fragmentation may be deleterious for patients with heart failure.
心力衰竭住院后的再入院患者中，高达五分之一是在不同医院进行的。这对信息连续性产生了负面影响，但再入院地点是否会影响后续结果尚不清楚。
对2004年4月至2013年12月期间在加拿大以心力衰竭为主要诊断出院的所有患者进行回顾性队列研究。我们比较了30天内再次入住原医院与不同医院的患者。在217039例心力衰竭患者（平均年龄76.8岁，50.1%为男性）中，39368例（18.1%）在30天内再次入院，其中32771例（83.2%）再次入住原医院，6597例（16.8%）入住不同医院（从2004年的15.6%随时间增加到2013年的18.5%；趋势P=0.001）。再次入住不同医院的患者更年轻，更可能为男性，居住在农村，出院年份更近，首次住院在教学医院，再入院时由救护车送来。再次入住原医院的时间明显更短（平均10.4天[95%CI，10.3 - 10.6]对11.6天[95%CI，11.3 - 12.0]；调整后均值，11.0对12.0；P<0.0001），且死亡率低于再次入住不同医院的患者（14.4%对15.0%；调整后比值比，0.89；95%CI，0.82 - 0.96）。
随着时间的推移，在不同医院的再入院情况越来越频繁，与再次入住原医院相比，住院时间更长，死亡率更高。我们的研究结果进一步证明，医疗服务碎片化可能对心力衰竭患者有害。
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