Thorsteinsdottir Bjorg, Peterson Stephanie M, Naessens James M, Mccoy Rozalina G, Hanson Gregory J, Hickson Latonya J, Chen Christina Yy, Rahman Parvez A, Shah Nilay D, Borkenhagen Lynn, Chandra Anupam, Havyer Rachel, Leppin Aaron, Takahashi Paul Y
Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, Minnesota.
Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.
J Hosp Med. 2019 Jun 1;14(6):329-335. doi: 10.12788/jhm.3112. Epub 2019 Feb 20.
Although posthospitalization care transitions programs (CTP) are highly diverse, their overall program thoroughness is most predictive of their success.
To identify components of a successful homebased CTP and patient characteristics that are most predictive of reduced 30-day readmissions.
Retrospective cohort.
A total of 315 community-dwelling, hospitalized, older adults (≥60 years) at high risk for readmission (Elder Risk Assessment score ≥16), discharged home over the period of January 1, 2011 to June 30, 2013.
Midwest primary care practice in an integrated health system.
Enrollment in a CTP during acute hospitalization.
The primary outcome was all-cause readmission within 30 days of the first CTP evaluation. Logistic regression was used to examine independent variables, including patient demographics, comorbidities, number of medications, completion, and timing of program fidelity measures, and prior utilization of healthcare.
The overall 30-day readmission rate was 17.1%. The intensity of follow-up varied among patients, with 17.1% and 50.8% of the patients requiring one and ≥3 home visits, respectively, within 30 days. More than half (54.6%) required visits beyond 30 days. Compared with patients who were not readmitted, readmitted patients were less likely to exhibit cognitive impairment (29.6% vs 46.0%; P = .03) and were more likely to have high medication use (59.3% vs 44.4%; P = .047), more emergency department (ED; 0.8 vs 0.4; P = .03) and primary care visits (4.0 vs 3.0; P = .018), and longer cumulative time in the hospital (4.6 vs 2.5 days; P = .03) within 180 days of the index hospitalization. Multivariable analysis indicated that only cognitive impairment and previous ED visits were important predictors of readmission.
No single CTP component reliably predicted reduced readmission risk. Patients with cognitive impairment and polypharmacy derived the most benefit from the program.
尽管住院后护理过渡计划（CTP）多种多样，但其整体计划的完备程度最能预测其成功与否。
确定成功的居家CTP的组成部分以及最能预测30天再入院率降低的患者特征。
回顾性队列研究。
2011年1月1日至2013年6月30日期间，共有315名社区居住、曾住院、有再入院高风险（老年人风险评估得分≥16）且年龄≥60岁的老年人出院回家。
综合卫生系统中的中西部初级保健机构。
在急性住院期间参加CTP。
主要结局是首次CTP评估后30天内的全因再入院情况。采用逻辑回归分析来检验自变量，包括患者人口统计学特征、合并症、用药数量、计划保真度测量的完成情况和时间，以及先前的医疗保健利用情况。
30天的总体再入院率为17.1%。患者的随访强度各不相同，分别有17.1%和50.8%的患者在30天内需要进行1次和≥3次家访。超过一半（54.6%）的患者需要在30天后进行家访。与未再入院的患者相比，再入院患者出现认知障碍的可能性较小（29.6%对46.0%；P = 0.03），用药量大的可能性较大（59.3%对44.4%；P = 0.047），在首次住院后180天内急诊就诊次数更多（0.8次对0.4次；P = 0.03）、初级保健就诊次数更多（4.0次对3.0次；P = 0.018），且累计住院时间更长（4.6天对2.5天；P = 0.03）。多变量分析表明，只有认知障碍和先前的急诊就诊是再入院的重要预测因素。
没有单一的CTP组成部分能可靠地预测再入院风险降低。认知障碍和多重用药的患者从该计划中获益最大。
