Teno J, Lynn J, Connors A F, Wenger N, Phillips R S, Alzola C, Murphy D P, Desbiens N, Knaus W A
Center to Improve Care of the Dying, George Washington University Medical Center, Washington, DC 20037, USA.
J Am Geriatr Soc. 1997 Apr;45(4):513-8. doi: 10.1111/j.1532-5415.1997.tb05180.x.
Would increasing the documentation of advance directives (ADs) lead to a reduction in resource utilization? We examined this question by conducting three secondary analyses: (1) we tested for a change in resource use among those who died in the hospital at a time before and after an intervention that increased the documentation of ADs in the medical record; (2) we replicated analyses of published studies that reported an association of chart documentation of ADs and hospital resource use; and (3) we examined whether a potential explanation of the observed association is biased documentation of ADs among patients who have completed an AD.
Replication of analysis of previous published studies using data from a prospective cohort study and block-randomized controlled trial.
Five teaching hospitals in the United States.
A total of 9105 seriously ill patients were enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), including 4301 patients in the 2 years (1989-91) before the Patient Self-Determination Act (PSDA) and 4804 in the 2 years (1992-94) after the PSDA implementation, with 2652 patients receiving the intervention and 2152 serving as controls.
The SUPPORT intervention provided a nurse to facilitate communication among patients, surrogates, and physicians about preferences for and outcomes of treatments. Documenting existing advance directives was also one of this nurse's tasks. The Patient Self-Determination Act required that health care institutions inquire about and document existing advance directives at the time of hospital admission.
Hospital resource use was derived from the Therapeutic Intensity Scoring System and hospital length of stay, converted into 1994 dollars.
Chart documentation of existing advance directives at the time of study admission increased with both the PSDA and the SUPPORT intervention. We found that intervention patients were more likely to have pre-existing ADs documented. Despite this increase, there was no corresponding change in hospital resource use for those who died during the enrollment hospitalization. Replication of analyses from published studies using data from the block randomized controlled trial found that ADs documented by the third day of serious illness were associated with a 23% reduction in hospital resource use among control patients ($21,284 with ADs documented compared with $26,127 without, 95% CI 1-48% reduction). However, this association was not observed among intervention patients, who had more pre-existing ADs documented in the medical record. Intervention patients with early documentation of ADs showed a trend toward greater cost ($28,017 compared with $24,178 among those without AD documentation, 95% CI 0-25% increase). The rate of documentation and characteristics of those with documentation differed between control and intervention patients. Intervention patients were more likely (as reported by patient or surrogate interview) to have ADs documented in the medical record by the third day (55% vs 32%, P < .001). In contrast to intervention patients, control patients who were older, less wealthy, less educated, more likely to prefer to forgo CPR, and more likely to want life-sustaining treatment limited had their ADs documented. These associations were not found among intervention patients when comparison was made between those with and those without an AD documented in the medical record.
Increasing the documentation of pre-existing ADs was not associated with a reduction in hospital resource use. ADs documented without further intervention by the third day of a serious illness were associated with decreased hospital resource use. However, we did not find this association with an intervention that increased AD documentation. One potential explanation of these findings is that classification of those with an AD was based on cha
增加预先指示（ADs）的记录是否会导致资源利用的减少？我们通过进行三项二次分析来研究这个问题：（1）我们测试了在一项增加病历中ADs记录的干预措施前后，医院中死亡患者的资源使用变化；（2）我们重复了已发表研究中关于ADs图表记录与医院资源使用之间关联的分析；（3）我们研究了观察到的关联的一个潜在解释是否是已完成ADs的患者中ADs记录存在偏差。
使用前瞻性队列研究和整群随机对照试验的数据对先前发表的研究分析进行重复。
美国的五家教学医院。
共有9105名重症患者参加了“了解治疗结果和风险的预后及偏好研究”（SUPPORT），其中包括《患者自我决定法案》（PSDA）实施前两年（1989 - 91年）的4301名患者和PSDA实施后两年（1992 - 94年）的4804名患者，2652名患者接受干预，2152名患者作为对照。
SUPPORT干预提供一名护士，以促进患者、代理人和医生之间关于治疗偏好和结果的沟通。记录现有的预先指示也是该护士的任务之一。《患者自我决定法案》要求医疗机构在患者入院时询问并记录现有的预先指示。
医院资源使用来自治疗强度评分系统和住院时间，并换算为1994年美元。
研究入院时现有预先指示的图表记录随着PSDA和SUPPORT干预而增加。我们发现干预组患者更有可能记录有预先存在的ADs。尽管有这种增加，但在入组住院期间死亡的患者中，医院资源使用没有相应变化。使用整群随机对照试验的数据对已发表研究的分析进行重复发现，在重病第三天记录的ADs与对照组患者的医院资源使用减少23%相关（记录有ADs的患者为21,284美元，未记录的患者为26,127美元，95%CI为减少1 - 48%）。然而，在干预组患者中未观察到这种关联，他们的病历中记录有更多预先存在的ADs。早期记录ADs的干预组患者显示出成本增加的趋势（记录有ADs的患者为28,017美元，未记录的患者为24,178美元，95%CI为增加0 - 25%）。对照组和干预组患者在记录率和记录者特征方面存在差异。干预组患者更有可能（根据患者或代理人访谈报告）在第三天在病历中记录有ADs（55%对32%；P <.001）。与干预组患者不同，年龄较大、财富较少、教育程度较低、更倾向于放弃心肺复苏以及更希望限制维持生命治疗的对照组患者记录了他们的ADs。当对病历中有ADs记录和没有ADs记录的干预组患者进行比较时，未发现这些关联。
增加现有ADs的记录与医院资源使用的减少无关。在重病第三天未经进一步干预而记录的ADs与医院资源使用的减少相关。然而，我们在一项增加ADs记录的干预措施中未发现这种关联。这些发现的一个潜在解释是，有ADs的患者的分类是基于……
