University of Rochester Medical Center, School of Nursing, Rochester, New York, USA.
School of Nursing, Vanderbilt University, Nashville, Tennessee, USA.
BMJ Open. 2019 Jan 29;9(1):e024766. doi: 10.1136/bmjopen-2018-024766.
(1) To compare changes in vulnerability after hospital discharge among older patients with cardiovascular disease who were discharged home with self-care versus a home healthcare (HHC) referral and (2) to examine factors associated with changes in vulnerability in this period.
Secondary analysis of longitudinal data from a cohort study.
834 older (≥65 years) patients hospitalised for acute coronary syndromes and/or acute decompensated heart failure who were discharged home with self-care (n=713) or an HHC referral (n=121).
Vulnerability was measured using Vulnerable Elders Survey 13 (VES-13) at baseline (prior to hospital admission) and 30 days and/or 90 days after hospital discharge. Effects of HHC referral on postdischarge change in vulnerability were examined using three linear regression approaches, with potential confounding on HHC referral adjusted by propensity score matching.
Overall, 44.4% of the participants were vulnerable at prehospitalisation baseline and 34.4% were vulnerable at 90 days after hospital discharge. Compared with self-care patients, HHC-referred patients were more vulnerable at baseline (66.9% vs 40.3%), had more increase (worsening) in VES-13 score change (B=-1.34(-2.07, -0.61), p<0.001) in the initial 30 days and more decrease (improvement) in VES-13 score change (B=0.83(0.20, 1.45), p=0.01) from 30 to 90 days after hospital discharge. Baseline vulnerability and the HHC referral attributed to 14%-16% of the variance in vulnerability change during the 90 postdischarge days, and 6% was attributed by patient age, race (African-American), depressive symptoms, and outpatient visits and hospitalisations in the past year.
After adjusting for preceding vulnerability and covariates, older hospitalised patients with cardiovascular disease referred to HHC had delayed recovery in vulnerability in first initial 30 days after hospital discharge and greater improvement in vulnerability from 30 to 90 days after hospital discharge. HHC seemed to facilitate improvement in vulnerability among older patients with cardiovascular disease from 30 to 90 days after hospital discharge.
（1）比较出院后患有心血管疾病的老年患者在家中接受自我护理与家庭保健（HHC）转介出院后的脆弱性变化，（2）探讨在此期间脆弱性变化的相关因素。
对一项队列研究的纵向数据进行二次分析。
834 名（≥65 岁）因急性冠状动脉综合征和/或急性失代偿性心力衰竭住院的老年患者，其中 713 名在家中接受自我护理出院，121 名接受 HHC 转介出院。
使用脆弱性老年人调查 13 项（VES-13）在基线（入院前）和出院后 30 天和/或 90 天测量脆弱性。使用三种线性回归方法检查 HHC 转介对出院后脆弱性变化的影响，并通过倾向评分匹配调整 HHC 转介的潜在混杂因素。
总体而言，44.4%的参与者在入院前基线时处于脆弱状态，34.4%在出院后 90 天处于脆弱状态。与自我护理患者相比，HHC 转介患者在基线时更脆弱（66.9%比 40.3%），在最初 30 天内 VES-13 评分变化更大（B=-1.34（-2.07，-0.61），p<0.001），出院后 30 至 90 天内 VES-13 评分变化更小（B=0.83（0.20，1.45），p=0.01）。基线脆弱性和 HHC 转介解释了出院后 90 天内脆弱性变化的 14%-16%，而患者年龄、种族（非裔美国人）、抑郁症状以及过去一年的门诊和住院就诊次数则解释了 6%。
在校正了先前的脆弱性和协变量后，接受 HHC 转介的患有心血管疾病的老年住院患者在出院后最初的 30 天内脆弱性恢复延迟，从出院后 30 天至 90 天内脆弱性改善更大。HHC 似乎有助于改善出院后 30 至 90 天内患有心血管疾病的老年患者的脆弱性。
