Indiana University Richard M. Fairbanks School of Public Health at Indianapolis, Indianapolis, IN.
Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN.
J Am Med Dir Assoc. 2020 Apr;21(4):545-549.e1. doi: 10.1016/j.jamda.2020.02.002.
The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project led to significant decreases in potentially avoidable hospitalizations of long-stay nursing facility residents in external evaluation. The purpose of this study was to quantify hospitalization risk from the start of the project and describe the heterogeneity of the enrolled facilities in order to better understand the context for successful implementation.
Pre-post analysis design of a prospective intervention within a single group.
A total of 4320 residents in the 19 facilities were included from admission until time to the first hospitalization.
Data were extracted from Minimum Data Set assessments and linked with facility-level covariates from the LTCFocus.org data set. Kaplan-Meier and Cox proportional hazards regression were used to assess risk of hospitalization during the preintervention period (2011-2012), a "ramp-up" period (2013-2014), and an intervention period (2015-2016).
The cohort consisted of 4230 long-stay nursing facility residents. Compared with the preintervention period, residents during the intervention period had an increased probability of having no hospitalizations within 1 year, increasing from 0.51 to 0.57, which was statistically significant (P < .001). In adjusted Cox models, the risk of hospitalization was lower in the ramp-up period compared to the pre-period [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.75-0.95] and decreased further during the intervention period (HR 0.74, 95% CI 0.65-0.84).
As part of a large multisite demonstration project, OPTIMISTIC has successfully reduced hospitalizations. However, this study highlights the magnitude and extent to which results differ across facilities. Implementing the OPTIMISTIC program was associated with a 16% risk reduction after the first 18 months and continued to a final risk reduction of 26% after 5½ years. Although this model of care reduces hospitalizations overall, facility variation should be expected.
优化患者转院、提升医疗质量和改善症状：转化机构护理（OPTIMISTIC）项目在外部评估中显著降低了长期护理机构居民可避免住院的数量。本研究的目的是从项目开始量化住院风险，并描述参与机构的异质性，以便更好地了解成功实施的背景。
在单一组内进行的前瞻性干预的前后分析设计。
共纳入了 19 家机构的 4320 名入住居民，从入院到首次住院期间进行了数据采集。
从最低数据集评估中提取数据，并与 LTCFocus.org 数据集的机构水平协变量进行关联。采用 Kaplan-Meier 和 Cox 比例风险回归来评估干预前（2011-2012 年）、“爬坡期”（2013-2014 年）和干预期（2015-2016 年）的住院风险。
队列包括 4230 名长期护理机构居民。与干预前相比，干预期间的居民在 1 年内无住院的概率增加，从 0.51 增加到 0.57，差异具有统计学意义（P<0.001）。在调整后的 Cox 模型中，爬坡期的住院风险低于干预前（风险比[HR]0.85，95%置信区间[CI]0.75-0.95），并且在干预期间进一步降低（HR 0.74，95%CI 0.65-0.84）。
作为一项大型多站点示范项目的一部分，OPTIMISTIC 成功降低了住院率。然而，这项研究强调了结果在各机构之间的巨大差异和程度。在最初的 18 个月后，实施 OPTIMISTIC 计划与 16%的风险降低相关，并且在 5 年半后继续降低 26%的风险。尽管这种护理模式总体上降低了住院率，但应预期会出现机构间的差异。
