Kane Robert L, Huckfeldt Peter, Tappen Ruth, Engstrom Gabriella, Rojido Carolina, Newman David, Yang Zhiyou, Ouslander Joseph G
University of Minnesota School of Public Health, Minneapolis.
Florida Atlantic University, Christine E. Lynn College of Nursing, Boca Raton.
JAMA Intern Med. 2017 Sep 1;177(9):1257-1264. doi: 10.1001/jamainternmed.2017.2657.
Medicare payment initiatives are spurring efforts to reduce potentially avoidable hospitalizations.
To determine whether training and support for implementation of a nursing home (NH) quality improvement program (Interventions to Reduce Acute Care Transfers [INTERACT]) reduced hospital admissions and emergency department (ED) visits.
DESIGN, SETTING, AND PARTICIPANTS: This analysis compared changes in hospitalization and ED visit rates between the preintervention and postintervention periods for NHs randomly assigned to receive training and implementation support on INTERACT to changes in control NHs. The analysis focused on 85 NHs (36 717 NH residents) that reported no use of INTERACT during the preintervention period.
The study team provided training and support for implementing INTERACT, which included tools that help NH staff identify and evaluate acute changes in NH resident condition and document communication between physicians; care paths to avoid hospitalization when safe and feasible; and advance care planning and quality improvement tools.
All-cause hospitalizations, hospitalizations considered potentially avoidable, 30-day hospital readmissions, and ED visits without admission. All-cause hospitalization rates were calculated for all resident-days, high-risk days (0-30 days after NH admission), and lower-risk days (≥31 days after NH admission).
We found that of 85 NHs, those that received implementation training and support exhibited statistically nonsignificant reductions in hospitalization rates compared with control NHs (net difference, -0.13 per 1000 resident-days; P = .25), hospitalizations during the first 30 days after NH admission (net difference, -0.37 per 1000 resident-days; P = .48), hospitalizations during periods more than 30 days after NH admission (net difference, -0.09 per 1000 resident-days; P = .39), 30-day readmission rates (net change in rate among hospital discharges, -0.01; P = .36), and ED visits without admission (net difference, 0.02 per 1000 resident-days; P = .83). Intervention NHs exhibited a reduction in potentially avoidable hospitalizations overall (net difference, -0.18 per 1000 resident-days, P = .01); however, this effect was not robust to a Bonferroni correction for multiple comparisons.
Training and support for INTERACT implementation as carried out in this study had no effect on hospitalization or ED visit rates in the overall population of residents in participating NHs. The results have several important implications for implementing quality improvement initiatives in NHs.
clinicaltrials.gov Identifier: NCT02177058.
医疗保险支付举措正在推动各方努力减少潜在可避免的住院情况。
确定针对实施疗养院（NH）质量改进计划（减少急性护理转移干预措施[INTERACT]）的培训和支持是否能降低住院率和急诊室（ED）就诊率。
设计、设置和参与者：本分析比较了随机分配接受INTERACT培训和实施支持的NH疗养院在干预前和干预后期间住院率和ED就诊率的变化，以及对照NH疗养院的变化。分析聚焦于85家NH疗养院（36717名NH居民），这些疗养院在干预前期报告未使用INTERACT。
研究团队为实施INTERACT提供培训和支持，包括帮助NH工作人员识别和评估NH居民病情急性变化并记录医生之间沟通的工具；在安全可行时避免住院的护理路径；以及预先护理规划和质量改进工具。
全因住院、被认为可能可避免的住院、30天再住院率以及未住院的ED就诊。计算所有居民日、高风险日（NH入院后0至30天）和低风险日（NH入院后≥31天）的全因住院率。
我们发现，在85家NH疗养院中，接受实施培训和支持的疗养院与对照NH疗养院相比，住院率虽有下降但无统计学意义（净差异为每1000居民日 -0.13；P = 0.25），NH入院后头30天的住院率（净差异为每1000居民日 -0.37；P = 0.48），NH入院30天以上期间的住院率（净差异为每1000居民日 -0.09；P = 0.39），30天再住院率（出院率的净变化，-0.01；P = 0.36），以及未住院的ED就诊率（净差异为每1000居民日0.02；P = 0.83）。干预NH疗养院总体上在可能可避免的住院方面有所下降（净差异为每1000居民日 -0.18，P = 0.01）；然而，对于多重比较的Bonferroni校正，这种效果并不稳健。
本研究中实施的针对INTERACT实施的培训和支持对参与的NH疗养院居民总体人群的住院率或ED就诊率没有影响。这些结果对在NH疗养院实施质量改进举措有几个重要意义。
clinicaltrials.gov标识符：NCT02177058。
