Reker D M, O'Donnell J C, Hamilton B B
Epidemiology Research and Information Center, Veterans Affairs Medical Center, Durham, North Carolina 27705, USA.
Arch Phys Med Rehabil. 1998 Jul;79(7):751-7. doi: 10.1016/s0003-9993(98)90351-3.
To assess variation in stroke outcomes and create a case-mix adjustment model for stroke rehabilitation in Veterans Affairs Medical Centers.
Observational
Within Veteran's Health Administration hospitals, there are 63 acute rehabilitation bedservice units that care for approximately 2,000 stroke patients annually.
Functional gain in FIM points, length of stay (LOS), LOS efficiency (FIM gain/LOS).
Significant variation in average patient functional gain, LOS, and LOS efficiency was observed among the 37 highest-volume rehabilitation units. Using analysis of covariance, a model was developed that adjusted functional gain and LOS (logged LOS) unit means using 10 potential covariates identified in a literature review and in pilot studies. Four and six covariates, respectively, were retained in the final models for FIM gain and LOS. The R2 for FIM gain and LOS accounted for by rehabilitation unit alone increased from .07 to .31 (FIM gain) and from .13 to .34 (logLOS) with the addition of the significant covariates to each model.
As much as 24% of the variation in two important stroke rehabilitation outcomes is attributable to largely immutable patient and system characteristics (eg, patient function on admission, age, days since stroke onset, year of discharge, marital status, and referral source). Hence, controlling for case-mix is critical for accurate comparison of unit outcomes. Further, the variation in LOS efficiency between VA rehabilitation units suggests a large potential for cost and resource utilization savings system-wide.
评估退伍军人事务医疗中心中风康复结局的差异，并创建一个中风康复的病例组合调整模型。
观察性研究
在退伍军人健康管理局的医院内，有63个急性康复病床服务单元，每年照料约2000名中风患者。
功能独立性测量（FIM）得分的功能改善、住院时间（LOS）、住院时间效率（FIM改善/LOS）。
在37个最高流量的康复单元中，观察到患者平均功能改善、住院时间和住院时间效率存在显著差异。使用协方差分析，开发了一个模型，该模型使用在文献综述和试点研究中确定的10个潜在协变量来调整功能改善和住院时间（对数住院时间）的单元均值。最终的FIM改善模型和住院时间模型分别保留了4个和6个协变量。随着每个模型中加入显著协变量，仅由康复单元解释的FIM改善和住院时间的R2分别从0.07增加到0.31（FIM改善）和从0.13增加到0.34（对数住院时间）。
在两个重要的中风康复结局中，高达24%的差异主要归因于患者和系统的不可改变特征（例如，入院时的患者功能、年龄、中风发作后的天数、出院年份、婚姻状况和转诊来源）。因此，控制病例组合对于准确比较单元结局至关重要。此外，退伍军人事务部康复单元之间住院时间效率的差异表明，在全系统范围内节省成本和资源利用方面有很大潜力。
