Rosenthal G E, Harper D L, Shah A, Covinsky K E
Department of Medicine, Case Western Reserve University School of Medicine, OH, USA.
J Gen Intern Med. 1997 Jul;12(7):416-22. doi: 10.1046/j.1525-1497.1997.00073.x.
Determine patient and hospital-level variation in proportions of low-severity admissions.
Retrospective cohort study.
Thirty hospitals in a large metropolitan region.
A total of 43,209 consecutive eligible patients discharged in 1991 through 1993 with congestive heart failure (n = 25,213) or pneumonia (n = 17,995).
Admission severity of illness was measured from validated multivariable models that estimated the risk of in-hospital death; models were based on clinical data abstracted from patients' medical records. Admissions were categorized as "low severity" if the predicted risk of death was less than 1%. Nearly 15% of patients (n = 6,382) were categorized as low-severity admissions. Compared with other patients, low-severity admissions were more likely (p < .001) to be nonwhite and to have Medicaid or be uninsured. Low-severity admissions had shorter median length of stay (4 vs 7 days; p < .001), but accounted for 10% of the total number of hospital days. For congestive heart failure, proportions of low-severity admissions across hospitals ranged from 10% to 25%; 12 hospitals had rates that were significantly different (p < .01) than the overall rate of 17%. For pneumonia, proportions ranged from 3% to 22%; 12 hospitals had rates different from the overall rate of 12%. Variation across hospitals remained after adjusting for patient sociodemographic factors.
Rates of low-severity admissions for congestive heart failure and pneumonia varied across hospitals and were higher among nonwhite and poorly insured patients. Although the current study does not identify causes of this variability, possible explanations include differences in access to ambulatory services, decisions to admit patients for clinical indications unrelated to the risk of hospital mortality, and variability in admission practices of individual physicians and hospitals. The development of protocols for ambulatory management of low-severity patients and improvement of access to outpatient care would most likely decrease the utilization of more costly hospital services.
确定低严重程度入院患者比例在患者层面和医院层面的差异。
回顾性队列研究。
一个大都市地区的30家医院。
1991年至1993年期间连续出院的共43209例符合条件的患者，其中充血性心力衰竭患者25213例，肺炎患者17995例。
采用经过验证的多变量模型测量入院时的疾病严重程度，该模型估计住院死亡风险；模型基于从患者病历中提取的临床数据。如果预测死亡风险低于1%，则将入院归类为“低严重程度”。近15%的患者（n = 6382）被归类为低严重程度入院。与其他患者相比，低严重程度入院患者更有可能（p < 0.001）为非白人，且有医疗补助或未参保。低严重程度入院患者的中位住院时间较短（4天对7天；p < 0.001），但占总住院天数的10%。对于充血性心力衰竭，各医院低严重程度入院患者的比例在10%至25%之间；12家医院的比例与总体比例17%有显著差异（p < 0.01）。对于肺炎，比例在3%至22%之间；12家医院的比例与总体比例12%不同。在调整患者社会人口学因素后，医院间的差异仍然存在。
充血性心力衰竭和肺炎的低严重程度入院率在各医院之间存在差异，在非白人和保险状况较差的患者中更高。尽管当前研究未确定这种差异的原因，但可能的解释包括门诊服务可及性的差异、因与医院死亡风险无关的临床指征而决定收治患者、以及个别医生和医院收治方式的差异。制定低严重程度患者门诊管理方案并改善门诊医疗可及性很可能会降低对成本更高的医院服务的利用。
