Ernecoff Natalie C, Altieri-Dunn Stefanie C, Bilderback Andrew, Wilson Cindy L, Saxon Susan, Ahuja Yende Namita, Arnold Robert M, Boninger Michael
Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
Wolff Center, UPMC, Pittsburgh, PA, USA.
J Am Med Dir Assoc. 2021 Nov;22(11):2389-2393. doi: 10.1016/j.jamda.2021.05.013. Epub 2021 Jun 8.
In the United States, people with serious illness often experience gaps and discontinuity in care. Gaps are frequently exacerbated by limited mobility, need for social support, and challenges managing multiple comorbidities. The Advanced Illness Care (AIC) Program provides nurse practitioner-led, home-based care for people with serious or complex chronic illnesses that specifically targets palliative care needs and coordinates with patients' primary care and specialty health care providers. We sought to investigate the effect of the AIC Program on hospital encounters [hospitalizations and emergency department (ED) visits], hospice conversion, and mortality.
Retrospective nearest-neighbor matching.
Patients in AIC who had ≥1 inpatient stay within the 60 days prior to AIC enrollment to fee-for-service Medicare controls at 9 hospitals within one health system.
We matched on demographic characteristics and comorbidities, with exact matches for diagnosis-related group and home health enrollment. Outcomes were hospital encounters (30- and 90-day ED visits and hospitalizations), hospice conversion, and 30- and 90-day mortality.
We included 110 patients enrolled in the AIC Program matched to 371 controls. AIC enrollees were mean age 77.0, 40.9% male, and 79.1% white. Compared with controls, AIC enrollees had a higher likelihood of ED visits at 30 [15.1 percentage points, confidence interval (CI) 4.9, 25.3; P = .004] and 90 days (27.8 percentage points, CI 16.0, 39.6; P < .001); decreased likelihood of hospitalization at 30 days (11.4 percentage points, CI -17.7, -5.0; P < .001); and a higher likelihood of converting to hospice (22.4 percentage points, CI 11.4, 33.3; P < .001).
The AIC Program provides care and coordination that the home-based serious illness population may not otherwise receive.
By identifying and addressing care needs and gaps in care early, patients may avoid unnecessary hospitalizations and receive timely hospice services as they approach the end of life.
在美国，重症患者常常经历医疗服务的缺口和不连续性。行动不便、需要社会支持以及应对多种合并症带来的挑战往往会加剧这些缺口。晚期疾病护理（AIC）项目为患有严重或复杂慢性病的患者提供由执业护士主导的居家护理，特别针对姑息治疗需求，并与患者的初级保健和专科医疗服务提供者进行协调。我们试图调查AIC项目对住院情况（住院治疗和急诊就诊）、临终关怀转换以及死亡率的影响。
回顾性最近邻匹配法。
在一个医疗系统内的9家医院中，AIC项目中在AIC登记前60天内有≥1次住院治疗的患者与按服务收费的医疗保险对照者。
我们根据人口统计学特征和合并症进行匹配，诊断相关组和家庭健康登记进行精确匹配。结果指标为住院情况（30天和90天的急诊就诊和住院治疗）、临终关怀转换以及30天和90天死亡率。
我们纳入了110名参加AIC项目的患者，并与371名对照者进行匹配。AIC项目参与者的平均年龄为77.0岁，男性占40.9%，白人占79.1%。与对照者相比，AIC项目参与者在30天（15.1个百分点，置信区间[CI] 4.9，25.3；P = .004）和90天（27.8个百分点，CI 16.0，39.6；P < .001）时急诊就诊的可能性更高；30天时住院可能性降低（11.4个百分点，CI -17.7，-5.0；P < .001）；转换至临终关怀的可能性更高（22.4个百分点，CI 11.4，33.3；P < .001）。
AIC项目提供了居家重症患者可能无法获得的护理和协调服务。
通过尽早识别和解决护理需求及护理缺口，患者在接近生命终点时可能避免不必要的住院治疗，并获得及时的临终关怀服务。
