Hospital Transfer Rates Among US Nursing Home Residents With Advanced Illness Before and After Initiatives to Reduce Hospitalizations
Hospital Transfer Rates Among US Nursing Home Residents With Advanced Illness Before and After Initiatives to Reduce Hospitalizations
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DOI：
10.1001/jamainternmed.2019.6130
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发表时间：
2020-03-01
影响因子：
39
通讯作者：
Mitchell, Susan L.
中科院分区：
文献类型：
--
作者：
McCarthy, Ellen P.;Ogarek, Jessica A.;Mitchell, Susan L.
在美国，被诊断出患有晚期疾病且预期寿命有限的疗养院居民之间的医院转移通常是负担沉重的，昂贵的，并且临床益处很少。自2012年以来推出的国家举措侧重于减少此类住院，但对这些举措在这一人群中的后果知之甚少。目的调查2011年至2017年国家减少住院治疗措施出台前后，老年痴呆症、充血性心力衰竭（CHF）和慢性阻塞性肺疾病（COPD）等晚期疾病养老院居民的医院转移率变化。在这项横断面研究中，从2011年1月1日到2016年12月31日，全国范围内的最小数据集（MDS）评估（随访转移率至2017年12月31日），用于确定长期住院的年度初始队列（>100天）最近进展到痴呆、CHF或COPD晚期的疗养院居民。分析了2018年10月24日至2019年10月3日的数据。主要结果和测量方法从MDS评估中计算出每人年的住院次数（住院，观察和急诊），从居民首次符合晚期疾病标准之日起至2011年至2017年使用Medicare索赔后12个月。研究了所有原因、可能避免的疾病（败血症、肺炎、脱水、尿路感染、CHF和COPD）和严重骨折（骨盆、髋关节、腕关节、踝关节和手臂或腿部长骨）的转移率。临终关怀登记人数和死亡率也已确定。结果2011年和2016年队列中接受任何医院转移的居民比例分别为晚期痴呆患者56.1%和45.4%，CHF患者77.6%和69.5%，COPD患者76.2%和67.2%。与2016年队列相比，2011年队列中因潜在可避免疾病而存活的平均（SD）转移人数更高：晚期痴呆，2.4（14.0）vs 1.6（11.2）（校正风险比[aRR]，0.73; 95% CI，0.65-0.81）; CHF，8.5（32.0）vs 6.7（26.8）（aRR，0.72; 95% CI，0.65-0.81）; COPD，7.8（30.9）vs 5.5（24.8）（aRR，0.64; 95% CI，0.57-0.72）。骨折的转移保持不变，死亡率没有增加。在所有疾病组和年份中，临终关怀的登记率都很低（范围为23%-30%）。结论和相关性本研究的结果表明，在采取旨在减少住院的新举措的同时，2011年至2017年间，患有晚期疾病的疗养院居民的转院率有所下降，但死亡率没有增加。机会仍然存在，以进一步减少不必要的医院转移，在这一人口和改善目标为导向的照顾，为那些居民谁选择放弃住院。一项横断面研究使用最小数据集评估来调查2011年至2017年期间美国养老院居民中晚期疾病患者的医院转移率，这些患者是在引入国家举措以减少住院治疗后出现的。在2011年至2017年期间，被诊断患有晚期疾病和预期寿命有限的疗养院居民在国家采取减少住院的举措之前和之后的医院转移率是否发生了变化？在这项对患有晚期疾病（如痴呆症，充血性心力衰竭和慢性阻塞性肺病）的6组养老院居民进行的美国全国性横断面研究中，尽管因各种原因和潜在可避免的疾病而进行的医院转移很常见，但发现这种转移从2011年到2017年大幅下降，所有队列中同时使用临终关怀的人数都很低。这项研究的结果表明，从2011年到2017年，患有晚期疾病的养老院居民的医院转移率有所下降，并且仍然有机会减少患有晚期疾病的居民不必要的医院转移。
Importance Hospital transfers among nursing home residents in the United States who have been diagnosed with advanced illnesses and have limited life expectancy are often burdensome, costly, and of little clinical benefit. National initiatives, introduced since 2012, have focused on reducing such hospitalizations, but little is known about the consequences of these initiatives in this population. Objective To investigate the change in hospital transfer rates among nursing home residents with advanced illnesses, such as dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), from 2011 to 2017-before and after the introduction of national initiatives to reduce hospitalizations. Design, Setting, and Participants In this cross-sectional study, nationwide Minimum Data Set (MDS) assessments from January 1, 2011, to December 31, 2016 (with the follow-up for transfer rates until December 31, 2017), were used to identify annual inception cohorts of long-stay (>100 days) nursing home residents who had recently progressed to the advanced stages of dementia, CHF, or COPD. The data were analyzed from October 24, 2018, to October 3, 2019. Main Outcomes and Measures The number of hospital transfers (hospitalizations, observation stays, and emergency department visits) per person-year alive was calculated from the MDS assessment from the date when residents first met the criteria for advanced illness up to 12 months afterward using Medicare claims from 2011 to 2017. Transfer rates for all causes, potentially avoidable conditions (sepsis, pneumonia, dehydration, urinary tract infections, CHF, and COPD), and serious bone fractures (pelvis, hip, wrist, ankle, and long bones of arms or legs) were investigated. Hospice enrollment and mortality were also ascertained. Results The proportions of residents in the 2011 and 2016 cohorts who underwent any hospital transfer were 56.1% and 45.4% of those with advanced dementia, 77.6% and 69.5% of those with CHF, and 76.2% and 67.2% of those with COPD. The mean (SD) number of transfers per person-year alive for potentially avoidable conditions was higher in the 2011 cohort vs 2016 cohort: advanced dementia, 2.4 (14.0) vs 1.6 (11.2) (adjusted risk ratio [aRR], 0.73; 95% CI, 0.65-0.81); CHF, 8.5 (32.0) vs 6.7 (26.8) (aRR, 0.72; 95% CI, 0.65-0.81); and COPD, 7.8 (30.9) vs 5.5 (24.8) (aRR, 0.64; 95% CI, 0.57-0.72). Transfers for bone fractures remained unchanged, and mortality did not increase. Hospice enrollment was low across all illness groups and years (range, 23%-30%). Conclusions and Relevance The findings of this study suggest that concurrent with new initiatives aimed at reducing hospitalizations, hospital transfers declined between 2011 and 2017 among nursing home residents with advanced illnesses without increased mortality rates. Opportunities remain to further reduce unnecessary hospital transfers in this population and improve goal-directed care for those residents who opt to forgo hospitalization.This cross-sectional study uses Minimum Data Set assessments to investigate the hospital transfer rates among nursing home residents in the United States with advanced illness between 2011 and 2017 after the introduction of national initiatives to reduce hospitalizations.Question How did the hospital transfer rates change between 2011 and 2017 among nursing home residents diagnosed with advanced illness and limited life expectancy before and after the introduction of national initiatives to reduce hospitalizations? Findings In this US nationwide cross-sectional study of 6 cohorts of nursing home residents with advanced illness, such as dementia, congestive heart failure, and chronic obstructive pulmonary disease, although hospital transfers for all causes and for potentially avoidable conditions were common, such transfers were found to have declined considerably from 2011 to 2017, and concurrent hospice use was low across all cohorts. Meaning The findings of this study suggest that hospital transfer rates among nursing home residents with advanced illness declined from 2011 to 2017 and that opportunities remain to reduce unnecessary hospital transfers among residents with advanced illness.