Can primary care visits reduce hospital utilization among medicare beneficiaries at the end of life?
Can primary care visits reduce hospital utilization among medicare beneficiaries at the end of life?
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DOI：
10.1007/s11606-008-0638-5
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发表时间：
2008-09-01
影响因子：
5.7
通讯作者：
Emanuel, Ezekiel J.
中科院分区：
文献类型：
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作者：
Kronman, Andrea C.;Ash, Arlene S.;Emanuel, Ezekiel J.
背景：临终时的医疗护理通常昂贵且无效。目的：探讨初级护理与临终时医院利用之间的关联。设计：医疗保险数据的回顾性分析。我们测量了生命最后 6 个月的医院利用率以及之前 12 个月的初级保健医生就诊次数。多变量聚类分析根据人口统计、合并症和地理对临终医疗保健利用的影响进行了调整。主题：对 2001 年去世的 78,356 名 66 岁以上医疗保险受益人进行全国随机抽样。非白人被过度抽样。所有受试者在死亡前 18 个月内拥有完整的医疗保险数据，除终末期肾病计划中的受试者外，均予以保留。测量：住院天数、费用、院内死亡以及生命最后 6 个月期间存在两种可预防的住院情况（门诊护理敏感病症）。结果：样本特征：38% 的初级保健就诊次数为 0 次； 22%, 1-2; 19%, 3-5; 10%，6-8； 11% 的访问次数超过 9 次。前一年进行更多初级保健就诊与临终时住院天数更少（没有初级保健就诊的患者为 15.3 天，就诊次数≥ 9 次的患者为 13.4 天，P < 0.001）、较低的费用（24,400 美元 vs. 23,400 美元，P < 0.05）、院内死亡人数较少（44% vs. 40%，P < 0.01）以及可预防的死亡人数较少相关充血性心力衰竭患者住院治疗 （调整后的比值比，aOR = 0.82，P < 0.001）和慢性阻塞性肺疾病（aOR = 0.81，P = 0.02）。结论：前一年的初级保健就诊与临终医院利用率较低且费用较低相关。增加医疗保险受益人的初级保健机会可能会降低成本并提高临终时的质量。
BACKGROUND: Medical care at the end of life is often expensive and ineffective.OBJECTIVE: To explore associations between primary care and hospital utilization at the end of life.DESIGN: Retrospective analysis of Medicare data. We measured hospital utilization during the final 6 months of life and the number of primary care physician visits in the 12 preceding months. Multivariate cluster analysis adjusted for the effects of demographics, comorbidities, and geography in end-of-life healthcare utilization.SUBJECTS: National random sample of 78,356 Medicare beneficiaries aged 66+ who died in 2001. Non-whites were over-sampled. All subjects with complete Medicare data for 18 months prior to death were retained, except for those in the End Stage Renal Disease program.MEASUREMENTS: Hospital days, costs, in-hospital death, and presence of two types of preventable hospital admissions (Ambulatory Care Sensitive Conditions) during the final 6 months of life.RESULTS: Sample characteristics: 38% had 0 primary care visits; 22%, 1-2; 19%, 3-5; 10%, 6-8; and 11%, 9+ visits. More primary care visits in the preceding year were associated with fewer hospital days at end of life (15.3 days for those with no primary care visits vs. 13.4 for those with >= 9 visits, P < 0.001), lower costs ($24,400 vs. $23,400, P < 0.05), less in-hospital death (44% vs. 40%, P < 0.01), and fewer preventable hospitalizations for those with congestive heart failure (adjusted odds ratio, aOR = 0.82, P < 0.001) and chronic obstructive pulmonary disease (aOR = 0.81, P = 0.02).CONCLUSIONS: Primary care visits in the preceding year are associated with less, and less costly, end-of-life hospital utilization. Increased primary care access for Medicare beneficiaries may decrease costs and improve quality at the end of life.