Welch H G, Wennberg D E, Welch W P
Veterans Affairs Medical Center, White River Junction, VT. 05009, USA.
N Engl J Med. 1996 Aug 1;335(5):324-9. doi: 10.1056/NEJM199608013350506.
Medicare's home health care program, consisting primarily of home visits by nurses and health aides, was conceived as a means to facilitate hospital discharge. Because home health care is now one of the fastest-growing categories of Medicare expenditures, we analyzed Medicare claims data to determine current patterns of use.
We used 1993 data from Medicare's National Claims History File to examine the temporal relation between home visits and hospital discharge, as well as the number of months Medicare enrollees received home health care. To determine whether home visits replaced hospital services, we calculated population-based utilization rates, adjusted for age and sex, for enrollees living in the 310 U.S. metropolitan statistical areas and determined whether the areas with higher rates of home health care also had lower admission rates or shorter lengths of stay. Finally, we compared the geographic variation in use of home health care with that of other Medicare services.
Roughly 3 million Medicare enrollees received over 160 million home health care visits in 1993. Seventy-eight percent of the visits either occurred more than a month after hospital discharge (35 percent) or were not associated with any inpatient care during the previous six months (43%). Home health care often represented a long-term intervention: 61 percent of the visits were to enrollees who received home health care for six months or more. We could find no evidence that home health care was substituted for hospital care; the metropolitan statistical areas with higher rates of home health care did not have fewer hospital admissions or shorter lengths of stay. There was more geographic variation in the use of home health care than in the use of other major categories of Medicare services (e.g., hospital admissions and physicians' services). Five states (all in the South) had more than 9000 visits per 1000 enrollees, and 14 states had fewer than 3000 visits per 1000 enrollees.
Home health care visits are used primarily to provide long-term care. There is no evidence that services provided at home replace hospital services, and the dramatic geographic variation in home visits suggests a lack of consensus about their appropriate use.
医疗保险的家庭医疗保健计划主要由护士和健康护理员上门访视组成，该计划原本旨在促进患者出院。由于家庭医疗保健如今是医疗保险支出中增长最快的类别之一，我们分析了医疗保险理赔数据，以确定当前的使用模式。
我们使用了医疗保险全国理赔历史档案中的1993年数据，来研究上门访视与出院之间的时间关系，以及医疗保险参保者接受家庭医疗保健的月数。为了确定上门访视是否取代了医院服务，我们计算了居住在美国310个大都市统计区的参保者基于人群的利用率，并根据年龄和性别进行了调整，以确定家庭医疗保健使用率较高的地区是否入院率较低或住院时间较短。最后，我们比较了家庭医疗保健使用情况的地理差异与其他医疗保险服务的地理差异。
1993年，约300万医疗保险参保者接受了超过1.6亿次家庭医疗保健访视。78%的访视要么发生在出院一个多月后（35%），要么与前六个月的任何住院治疗无关（43%）。家庭医疗保健通常代表一种长期干预：61%的访视对象是接受家庭医疗保健达六个月或更长时间的参保者。我们没有发现家庭医疗保健取代医院护理的证据；家庭医疗保健使用率较高的大都市统计区，其入院人数并未减少，住院时间也未缩短。家庭医疗保健使用情况的地理差异比其他主要医疗保险服务类别（如住院和医生服务）的地理差异更大。五个州（均在南部）每1000名参保者的访视次数超过9000次，14个州每1000名参保者的访视次数少于3000次。
家庭医疗保健访视主要用于提供长期护理。没有证据表明在家中提供的服务取代了医院服务，而且上门访视的巨大地理差异表明，对于其适当使用缺乏共识。
