一项预防老年充血性心力衰竭患者再入院的多学科干预措施。

A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure.

作者信息

Rich M W, Beckham V, Wittenberg C, Leven C L, Freedland K E, Carney R M

机构信息

Division of Cardiology, Jewish Hospital at Washington University, St. Louis, MO 63110, USA.

出版信息

N Engl J Med. 1995 Nov 2;333(18):1190-5. doi: 10.1056/NEJM199511023331806.

DOI:10.1056/NEJM199511023331806

PMID:7565975

Abstract

BACKGROUND

Congestive heart failure is the most common indication for admission to the hospital among older adults. Behavioral factors, such as poor compliance with treatment, frequently contribute to exacerbations of heart failure, a fact suggesting that many admissions could be prevented.

METHODS

We conducted a prospective, randomized trial of the effect of a nurse-directed, multidisciplinary intervention on rates of readmission within 90 days of hospital discharge, quality of life, and costs of care for high-risk patients 70 years of age or older who were hospitalized with congestive heart failure. The intervention consisted of comprehensive education of the patient and family, a prescribed diet, social-service consultation and planning for an early discharge, a review of medications, and intensive follow-up.

RESULTS

Survival for 90 days without readmission, the primary outcome measure, was achieved in 91 of the 142 patients in the treatment group, as compared with 75 of the 140 patients in the control group, who received conventional care (P = 0.09). There were 94 readmissions in the control group and 53 in the treatment group (risk ratio, 0.56; P = 0.02). The number of readmissions for heart failure was reduced by 56.2 percent in the treatment group (54 vs. 24, P = 0.04), whereas the number of readmissions for other causes was reduced by 28.5 percent (40 vs. 29, P not significant). In the control group, 23 patients (16.4 percent) had more than one readmission, as compared with 9 patients (6.3 percent) in the treatment group (risk ratio, 0.39; P = 0.01). In a subgroup of 126 patients, quality-of-life scores at 90 days improved more from base line for patients in the treatment group (P = 0.001). Because of the reduction in hospital admissions, the overall cost of care was $460 less per patient in the treatment group.

CONCLUSIONS

A nurse-directed, multidisciplinary intervention can improve quality of life and reduce hospital use and medical costs for elderly patients with congestive heart failure.

摘要

背景

充血性心力衰竭是老年人住院最常见的原因。行为因素，如治疗依从性差，常常导致心力衰竭病情加重，这一事实表明许多住院情况是可以预防的。

方法

我们对一项由护士主导的多学科干预措施的效果进行了一项前瞻性随机试验，该干预措施针对70岁及以上因充血性心力衰竭住院的高危患者，观察其出院后90天内的再入院率、生活质量和护理费用。干预措施包括对患者及其家属进行全面教育、规定饮食、社会服务咨询及早期出院计划、药物审查和强化随访。

结果

作为主要结局指标，治疗组142例患者中有91例在90天内未再入院存活，而接受常规护理的对照组140例患者中有75例（P = 0.09）。对照组有94例再入院，治疗组有53例（风险比，0.56；P = 0.02）。治疗组因心力衰竭再入院的次数减少了56.2%（54例对24例，P = 0.04），而因其他原因再入院的次数减少了28.5%（40例对29例，P无统计学意义）。对照组有23例患者（16.4%）有不止一次再入院，而治疗组有9例患者（6.3%）（风险比，0.39；P = 0.01）。在126例患者的亚组中，治疗组患者90天时的生活质量评分较基线改善更大（P = 0.001）。由于住院次数减少，治疗组每位患者的总体护理费用减少了460美元。