Nuckols Teryl K, Keeler Emmett, Morton Sally, Anderson Laura, Doyle Brian J, Pevnick Joshua, Booth Marika, Shanman Roberta, Arifkhanova Aziza, Shekelle Paul
Cedars-Sinai Medical Center, Los Angeles, California2RAND Corporation, Santa Monica, California.
RAND Corporation, Santa Monica, California.
JAMA Intern Med. 2017 Jul 1;177(7):975-985. doi: 10.1001/jamainternmed.2017.1136.
Quality improvement (QI) interventions can reduce hospital readmission, but little is known about their economic value.
To systematically review economic evaluations of QI interventions designed to reduce readmissions.
Databases searched included PubMed, Econlit, the Centre for Reviews & Dissemination Economic Evaluations, New York Academy of Medicine's Grey Literature Report, and Worldcat (January 2004 to July 2016).
Dual reviewers selected English-language studies from high-income countries that evaluated organizational or structural changes to reduce hospital readmission, and that reported program and readmission-related costs.
Dual reviewers extracted intervention characteristics, study design, clinical effectiveness, study quality, economic perspective, and costs. We calculated the risk difference and net costs to the health system in 2015 US dollars. Weighted least-squares regression analyses tested predictors of the risk difference and net costs.
Main outcomes measures included the risk difference in readmission rates and incremental net cost. This systematic review and data analysis is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.
Of 5205 articles, 50 unique studies were eligible, including 25 studies in populations limited to heart failure (HF) that included 5768 patients, 21 in general populations that included 10 445 patients, and 4 in unique populations. Fifteen studies lasted up to 30 days while most others lasted 6 to 24 months. Based on regression analyses, readmissions declined by an average of 12.1% among patients with HF (95% CI, 8.3%-15.9%; P < .001; based on 22 studies with complete data) and by 6.3% among general populations (95% CI, 4.0%-8.7%; P < .001; 18 studies). The mean net savings to the health system per patient was $972 among patients with HF (95% CI, -$642 to $2586; P = .23; 24 studies), and the mean net loss was $169 among general populations (95% CI, -$2610 to $2949; P = .90; 21 studies), reflecting nonsignificant differences. Among general populations, interventions that engaged patients and caregivers were associated with greater net savings ($1714 vs -$6568; P = .006).
Multicomponent QI interventions can be effective at reducing readmissions relative to the status quo, but net costs vary. Interventions that engage general populations of patients and their caregivers may offer greater value to the health system, but the implications for patients and caregivers are unknown.
质量改进（QI）干预措施可降低医院再入院率，但其经济价值鲜为人知。
系统评价旨在降低再入院率的QI干预措施的经济评估。
检索的数据库包括PubMed、Econlit、循证医学图书馆经济评估数据库、纽约医学院灰色文献报告以及Worldcat（2004年1月至2016年7月）。
两名评审员从高收入国家选取了英文研究，这些研究评估了旨在降低医院再入院率的组织或结构变革，并报告了项目及与再入院相关的成本。
两名评审员提取了干预特征、研究设计、临床疗效、研究质量、经济视角和成本。我们以2015年美元计算了风险差异和卫生系统的净成本。加权最小二乘回归分析检验了风险差异和净成本的预测因素。
主要结局指标包括再入院率的风险差异和增量净成本。本系统评价和数据分析按照系统评价与Meta分析的首选报告项目（PRISMA）指南进行报告。
在5205篇文章中，50项独特研究符合纳入标准，其中25项研究针对仅限于心力衰竭（HF）患者群体，涉及5768例患者；21项研究针对普通人群，涉及10445例患者；4项研究针对特殊人群。15项研究持续时间最长为30天，而其他大多数研究持续6至24个月。基于回归分析，HF患者的再入院率平均下降12.1%（95%CI，8.3%-15.9%；P < .001；基于22项有完整数据的研究），普通人群的再入院率平均下降6.3%（95%CI，4.0%-8.7%；P < .001；18项研究）。HF患者中，卫生系统每位患者的平均净节省为972美元（95%CI，-$642至2586美元；P = .23；24项研究），普通人群中平均净损失为169美元（95%CI，-$2610至2949美元；P = .90；21项研究），差异无统计学意义。在普通人群中，让患者及其照护者参与的干预措施与更大的净节省相关（1714美元对-$6568美元；P = .006）。
相对于现状，多成分QI干预措施在降低再入院率方面可能有效，但净成本各不相同。让普通患者群体及其照护者参与的干预措施可能对卫生系统具有更大价值，但对患者及其照护者的影响尚不清楚。
