重症监护病房中叙述性临床记录中记录的财务考虑因素的流行程度和性质。
Prevalence and Nature of Financial Considerations Documented in Narrative Clinical Records in Intensive Care Units.
机构信息
Mossavar-Rahmani Center for Business and Government, Harvard Kennedy School, Cambridge, Massachusetts.
Center for Quantitative Health, Division of Clinical Research and Center for Genomic Medicine, Massachusetts General Hospital, Boston.
出版信息
JAMA Netw Open. 2018 Nov 2;1(7):e184178. doi: 10.1001/jamanetworkopen.2018.4178.
IMPORTANCE
The extent to which financial considerations alter intensive care unit (ICU) decision making is poorly understood.
OBJECTIVES
To characterize the prevalence and nature of financial considerations documented in narrative clinical records and their association with patient-level demographic and clinical features.
DESIGN, SETTING, AND PARTICIPANTS: In silico cohort study applying natural language processing to narrative notes from the Medical Information Mart for Intensive Care (MIMIC-III) study. Data from all individuals hospitalized between June 1, 2001, and October 31, 2012, in the ICU of Beth Israel Deaconess Medical Center were analyzed from April 1 to April 30, 2018.
MAIN OUTCOMES AND MEASURE
Presence of financial considerations in narrative clinical notes.
RESULTS
Among 46 146 index ICU admissions, 1936 patients (4.2%) were identified with at least 1 note reflecting financial considerations during the ICU stay. Of these 1936 patients, 1135 (58.6%) were male, with a mean (SD) age of 38.8 (28.4) years and mean (SD) length of stay of 21.7 (27.1) days. Among the remaining 44 210 admissions in the cohort, 24 780 (56.1%) were male, with a mean (SD) age of 48.6 (32.1) years and mean (SD) length of stay of 9.2 (11.4) days. Among the 46 146 admissions, 142 (0.3%) included notes describing a change in the discharge plan, 142 (0.3%) describing a change in the treatment plan, and 303 (0.7%) describing a change in medication or previous nonadherence to medication associated with financial considerations. In logistic regression models adjusted for age, sex, marital status, and insurance type, longer hospital stays were significantly associated with the presence of financial notes (odds ratio, 1.01; 95% CI, 1.01-1.01).
CONCLUSIONS AND RELEVANCE
In this study, among patients in the ICU, clinical notes document the association of financial considerations with care decisions. Although such notes likely underestimate the frequency of such considerations, they highlight the need to develop better systematic approaches to understanding how financial constraints may alter care decisions in US health systems.
重要性
财务考虑因素对重症监护病房（ICU）决策的影响程度尚不清楚。
目的
描述记录在叙述性临床记录中的财务考虑因素的普遍性和性质，并分析其与患者水平的人口统计学和临床特征的关联。
设计、地点和参与者：本研究采用自然语言处理方法对 Beth Israel Deaconess Medical Center ICU 于 2001 年 6 月 1 日至 2012 年 10 月 31 日期间住院的所有患者的 MIMIC-III 研究中的医疗信息集市（MIMIC-III）研究中的叙述性笔记进行了基于计算机的队列研究。数据分析于 2018 年 4 月 1 日至 4 月 30 日进行。
主要结局和测量指标
叙述性临床记录中是否存在财务考虑因素。
结果
在 46146 例 ICU 入院患者中，有 1936 例（4.2%）至少有 1 份记录反映了 ICU 期间的财务考虑因素。在这 1936 例患者中，有 1135 例（58.6%）为男性，平均年龄（标准差）为 38.8（28.4）岁，平均住院时间为 21.7（27.1）天。在队列中的其余 44210 例入院患者中，有 24780 例（56.1%）为男性，平均年龄（标准差）为 48.6（32.1）岁，平均住院时间为 9.2（11.4）天。在 46146 例入院患者中，有 142 例（0.3%）的记录描述了出院计划的改变，142 例（0.3%）描述了治疗计划的改变，303 例（0.7%）描述了与财务考虑因素相关的药物改变或先前不遵医嘱。在调整年龄、性别、婚姻状况和保险类型的逻辑回归模型中，较长的住院时间与财务记录的存在显著相关（比值比，1.01；95%CI，1.01-1.01）。
结论和相关性
在这项研究中，ICU 患者的临床记录记录了财务考虑因素与护理决策之间的关联。尽管这些记录可能低估了这种考虑的频率，但它们强调了需要制定更好的系统方法来了解财务限制如何改变美国卫生系统中的护理决策。
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