Macpherson D S, Lofgren R P
Department of Medicine, University of Pittsburgh, Pittsburgh Veterans Affairs Medical Center, Pennsylvania 01540.
Med Care. 1994 May;32(5):498-507. doi: 10.1097/00005650-199405000-00008.
The purpose of this study was to evaluate the effect on resource use of a program outpatient internal medicine preoperative evaluation in a two arm parallel design randomized clinical trial. In a tertiary care teaching Veterans Affairs hospital, 355 patients (179 inpatient arm, 176 outpatient arm)(mean age 65.5 years) were referred for internal medicine preoperative evaluation before elective surgery. Outpatient internist preoperative evaluation was performed 2 to 3 weeks before admission for surgery in the experimental arm with preoperative laboratory and radiology testing performed during the visit. The control arm was admitted for surgery without outpatient evaluation. The main outcome measure was the length of stay. Preoperative length of stay was significantly reduced from 2.9 days in the inpatient arm to 1.6 days in the outpatient arm (P < 0.001, 95% confidence interval of the difference, -0.8 to -1.8 days). Postoperative length of stay in the outpatient arm (3.6 days) was slightly but not significantly longer than the inpatient arm (3.0 days) (95% confidence interval of the increase, -0.6 to 1.8 days). Total length of stay showed no significant difference between the outpatient (5.5 days) and inpatient (6.0 days) arms (95% confidence interval of the difference, -2.0 to 1.1 days). Unnecessary admissions, defined as patients admitted who were admitted but did not undergo surgery, were decreased significantly comparing the inpatient arm (12.3%) to the outpatient arm (5.7%) (95% confidence interval of the difference, 0.5% to 12.7%). Measures of resource use showed no difference between arms including laboratory tests (95% C.I. of the difference, -3.0 to 6.8 tests), imaging tests (95% C.I. of the difference, -0.5 to 0.8 tests) were administered. A significant increase in the use of consultants between the outpatient arm (1.3 consultations) and inpatient arm (0.9 consultations) was discovered (95% C.I. of the difference, 0.2 to 0.6). Patients health status after discharge and satisfaction with care were not different between the two arms of the investigation. A program of outpatient internal medicine preoperative evaluation significantly reduced preoperative length of stay with a lesser effect on total length of stay. Unnecessary admission of patients for elective surgery were reduced by this program.
本研究的目的是在一项双臂平行设计的随机临床试验中，评估内科门诊术前评估对资源利用的影响。在一家三级医疗教学退伍军人事务医院，355例患者（179例住院组，176例门诊组）（平均年龄65.5岁）在择期手术前被转介进行内科术前评估。在试验组中，门诊内科医生在手术入院前2至3周进行术前评估，并在就诊期间进行术前实验室和影像学检查。对照组直接入院手术，未进行门诊评估。主要结局指标是住院时间。术前住院时间从住院组的2.9天显著缩短至门诊组的1.6天（P<0.001，差异的95%置信区间为-0.8至-1.8天）。门诊组术后住院时间（3.6天）略长于住院组（3.0天），但差异不显著（增加的95%置信区间为-0.6至1.8天）。门诊组（5.5天）和住院组（6.0天）的总住院时间无显著差异（差异的95%置信区间为-2.0至1.1天）。将未进行手术但被收治的患者定义为不必要入院，与住院组（12.3%）相比，门诊组（5.7%）的不必要入院显著减少（差异的95%置信区间为0.5%至12.7%）。资源利用指标在两组之间无差异，包括实验室检查（差异的95%置信区间为-3.0至6.8项检查）、影像学检查（差异的95%置信区间为-0.5至0.8项检查）。发现门诊组（1.3次会诊）和住院组（0.9次会诊）之间会诊使用显著增加（差异的95%置信区间为0.2至0.6）。两组患者出院后的健康状况和对护理的满意度无差异。内科门诊术前评估方案显著缩短了术前住院时间，对总住院时间的影响较小。该方案减少了择期手术患者的不必要入院。
