Cher D J, Lenert L A
Division of General Internal Medicine, Palo Alto Veterans Affairs Health Care System, CA, USA.
JAMA. 1997 Sep 24;278(12):1001-7.
The worst outcome of critical care may not be death itself; rather, the worst may be an extended death process in which a patient's and his or her family's suffering has been prolonged by services that are ultimately impotent. We have previously used potentially ineffective care (PIC) as a proxy measure for this type of care.
To determine if PIC is delivered less often to Medicare patients enrolled in health maintenance organizations (HMOs) than those in traditional fee-for-service health plans.
All Medicare patients hospitalized in intensive care units in California during fiscal year 1994.
Potentially ineffective care was defined as the concurrence of in-hospital death or death within 100 days of hospital discharge and resource use (total hospital costs) above the 90th percentile.
Hospital costs were adjusted for institution-specific cost-to-charge ratios and local wage indices derived from Health Care Financing Administration cost reports. A multivariate regression model adjusted PIC rates for age, sex, race, elective admission to the hospital, Charlson index diseases, the 15 most common diagnosis related groups for death by 100 days, intensive care unit size, and number of residents at the hospital.
A total of 3914 (4.8%) of 81 494 patients experienced PIC and used 21.6% of total intensive care unit resources. The occurrence of PIC was less common among HMO members (adjusted odds ratio, 0.75; 95% confidence interval, 0.65-0.87). However, HMO members were not more likely to experience in-hospital death (adjusted odds ratio, 0.99; 95% confidence interval, 0.91-1.07) and only slightly more likely to experience death by 100 days after hospital discharge (adjusted odds ratio, 1.08; 95% confidence interval, 1.01-1.15).
Patients who experience PIC outcomes are not uncommon in the Medicare population, and patients experiencing this outcome consume a disproportionate amount of medical resources. Medicare beneficiaries in HMO practice settings had a lower risk of experiencing PIC outcomes after adjusting for age, sex, diagnosis, comorbid conditions, and characteristics of the treating hospital. This suggests that HMO practices may be better at limiting or avoiding injudicious use of critical care near the end of life.
重症监护最糟糕的结果可能并非死亡本身；相反，最糟糕的可能是一个延长的死亡过程，在此过程中，患者及其家人的痛苦因最终无效的医疗服务而被延长。我们之前曾使用潜在无效治疗（PIC）作为这类治疗的替代指标。
确定参加健康维护组织（HMO）的医疗保险患者接受PIC治疗的频率是否低于参加传统按服务收费健康计划的患者。
1994财年在加利福尼亚州重症监护病房住院的所有医疗保险患者。
潜在无效治疗被定义为住院死亡或出院后100天内死亡，且资源使用（医院总费用）高于第90百分位数。
根据医疗保健财务管理局成本报告得出的特定机构成本收费比率和当地工资指数，对医院成本进行调整。一个多变量回归模型对PIC率进行了年龄、性别、种族、择期入院、查尔森指数疾病、100天内死亡的15个最常见诊断相关组、重症监护病房规模以及医院住院医生数量的校正。
8,1494名患者中有3914名（4.8%）经历了PIC，消耗了21.6%的重症监护病房总资源。PIC在HMO成员中较少见（校正比值比，0.75；95%置信区间，0.65 - 0.87）。然而，HMO成员住院死亡的可能性并不更高（校正比值比，0.99；95%置信区间，0.91 - 支1.07），出院后100天内死亡的可能性仅略高（校正比值比，1.08；95%置信区间, 1.01 - 1.15）。
在医疗保险人群中，经历PIC结果的患者并不罕见，且经历此结果的患者消耗了不成比例的医疗资源。在对年龄、性别、诊断、合并症以及治疗医院特征进行校正后，HMO医疗机构中的医疗保险受益人经历PIC结果的风险较低。这表明HMO医疗机构可能在限制或避免临终时对重症监护的不当使用方面做得更好。
