Mor V, Intrator O, Fries B E, Phillips C, Teno J, Hiris J, Hawes C, Morris J
Center for Gerontology and Health Care Research, Brown University, Providence, RI 02912, USA.
J Am Geriatr Soc. 1997 Aug;45(8):1002-10. doi: 10.1111/j.1532-5415.1997.tb02973.x.
To compare the rates of hospitalization among cohorts of nursing home residents assembled before and after the implementation of the federally mandated Resident Assessment Instrument (RAI).
Subjects were nursing home residents chosen from 268 facilities in major Metropolitan Statistics Areas in 10 states and representing more than 1500 facilities and 60,000 residents. Two resident cohorts (1990 and 1993) were sampled (8 to 16 residents per facility, depending upon facility size) as part of an evaluation of the impact of implementing the RAI.
Research nurses reviewed records, interviewed staff, observed patients, and completed an RAI at baseline and 6 months later. All transitions during this interval (hospital admissions, nursing home transfers, returns home, death, etc.) were tracked. Using polytomous logistic regression, we tested the effect of cohort on the probability of being hospitalized in light of the competing risks of dying or remaining in the home, controlling for demographic and casemix variables, and having a DNR order in the chart.
A total of 4196 residents were studied, 2118 in 1990 (age 81.3, female 77.7%, LOS 6+ months 49.8%) and 2078 in 1993 (age 81.7, females 75.5%, LOS 6+ months 50.2%). The unadjusted probability of hospitalization dropped from .205 to .151. Multivariate analyses revealed a significant adjusted odds of hospitalization of .74 (95% CI .60-.91) and no cohort effect on home discharge or death. Among severely cognitively impaired residents, the adjusted odds of hospitalization in 1993 compared with the 1990 cohort was 0.74 (.53-1.03). Finally, among survivors in both cohorts who had a follow-up MDS performed, and whose ADL remained stable, 15.9% were hospitalized in 1990, whereas only 10.9% were hospitalized in 1993. On the other hand, ADL decliners were more likely to have been hospitalized in 1993 than in 1990 (40.6% vs 25.2%).
Although other changes in the industry, clinical practice, and health care policy may have influenced hospitalization of nursing home residents, the substantial reductions observed among the cognitively impaired and those with stable ADL suggest superior and uniform assessment information in the form of the RAI contributed significantly to this decline.
比较在联邦政府强制实施居民评估工具（RAI）之前和之后组建的养老院居民队列中的住院率。
研究对象为从10个州主要大都市统计区的268家机构中选取的养老院居民，这些机构代表了1500多家机构和60000名居民。作为对实施RAI影响评估的一部分，抽取了两个居民队列（1990年和1993年）（每个机构8至16名居民，取决于机构规模）。
研究护士查阅记录、访谈工作人员、观察患者，并在基线时和6个月后完成一份RAI。追踪此期间的所有转变情况（住院、转至其他养老院、回家、死亡等）。使用多分类逻辑回归，鉴于死亡或留在家中的竞争风险，我们检验了队列对住院概率的影响，同时控制人口统计学和病例组合变量，并考虑病历中有“不要复苏”（DNR）医嘱的情况。
共研究了4196名居民，1990年有2118名（年龄81.3岁，女性占77.7%，住院时间6个月及以上者占49.8%），1993年有2078名（年龄81.7岁，女性占75.5%，住院时间6个月及以上者占50.2%）。未调整的住院概率从0.205降至0.151。多变量分析显示，调整后的住院优势比为0.74（95%置信区间0.60 - 0.91），且队列对出院回家或死亡无影响。在重度认知障碍居民中，1993年与1990年队列相比，调整后的住院优势比为0.74（0.53 - 1.03）。最后，在两个队列中进行了随访最低数据集（MDS）且日常生活活动（ADL）保持稳定的幸存者中，1990年有15.9%住院，而1993年只有10.9%住院。另一方面，ADL下降者在1993年比1990年更有可能住院（40.6%对25.2%）。
尽管该行业、临床实践和医疗保健政策的其他变化可能影响了养老院居民的住院情况，但在认知障碍者和ADL稳定者中观察到的大幅下降表明，以RAI形式提供的优质且统一的评估信息对这种下降有显著贡献。
