One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study.
One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study.
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DOI：
10.7326/0003-4819-153-3-201008030-00007
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发表时间：
2010-08-03
影响因子：
39.2
通讯作者：
Cox CE
中科院分区：
文献类型：
--
作者：
Unroe M;Kahn JM;Carson SS;Govert JA;Martinu T;Sathy SJ;Clay AS;Chia J;Gray A;Tulsky JA;Cox CE
越来越多的重症患者接受长时间的机械通气。很少有人知道他们的护理模式，因为他们从急性医院过渡到急性后护理设施或相关的资源利用。描述长期机械通气患者的一年护理和资源利用轨迹。一年前瞻性队列研究。杜克大学医学中心的5个ICU。在一年内连续招募了126名长期机械通气患者及其126名代理人和54名ICU医生。长期机械通气定义为通气≥4天并放置气管造口术或通气≥21天但不进行气管造口术。在医院以及3个月和12个月后对患者和代理人进行了访谈，以确定患者的生存率、功能状态、设施类型和出院后护理的持续时间。在医院内对医生进行了访谈，以获得满意的结果。机构账单记录用于分配急性护理、门诊护理和机构间运输的费用。我们使用医疗保险索赔数据来分配急性期后护理的费用。103例（82%）住院幸存者在出院后护理地点经历了457次单独的转换（中位数4 [四分位距3，5]），包括68例（67%）至少再入院一次的患者。患者平均74%（CI，68%至80%）的所有生存日都在医院、急性后护理机构或接受家庭医疗保健。1年时，11例（9%）患者结局良好（存活，无功能依赖），33例（26%）结局一般（存活，中度依赖），82例（65%）结局较差（存活，完全功能依赖（n=4，21%）或死亡（n=56，44%）。结果较差的患者年龄较大，合并症较多，并且比结果一般或良好的患者更频繁地出院到急性期后护理机构（所有p <0.05）。每例患者的成本为306，135美元（SD 285，467美元），总队列成本总计为3810万美元，估计每名一年独立功能幸存者的成本为350万美元。本单中心研究的结果可能不适用于其他中心。长期机械通气患者经历多次护理转换，导致非常高的医疗保健成本和持续的严重残疾。在考虑延长生命支持过程时，替代决策者的乐观情绪应该通过对这些结果的讨论来平衡。
Growing numbers of critically ill patients receive prolonged mechanical ventilation. Little is known about their patterns of care as they transition from the acute hospital to post-acute care facilities or the associated resource utilization. To describe one-year trajectories of care and resource utilization for prolonged mechanical ventilation patients. One-year prospective cohort study. 5 ICUs at Duke University Medical Center. 126 prolonged mechanical ventilation patients as well as their 126 surrogates and 54 ICU physicians were enrolled consecutively during one year. Prolonged mechanical ventilation was defined as ventilation for ≥4 days with tracheostomy placement or ventilation for ≥21 days without tracheostomy. Patients and surrogates were interviewed in hospital, as well as 3 and 12 months later to determine patient survival, functional status, and facility type and duration of post-discharge care. Physicians were interviewed in-hospital to elicit prognoses. Institutional billing records were used to assign costs for acute care, outpatient care, and inter-facility transportation. We used Medicare claims data to assign costs for post-acute care. 103 (82%) hospital survivors experienced 457 separate transitions in post-discharge care location (median 4 [interquartile range 3, 5]), including 68 (67%) patients who were readmitted at least once. Patients spent an average of 74% (CI, 68% to 80%) of all days alive in a hospital, post-acute care facility, or receiving home health care. At one year, 11 (9%) patients had a good outcome (alive with no functional dependency), 33 (26%) had a fair outcome (alive with moderate dependency), and 82 (65%) had a poor outcome (either alive with complete functional dependency (n=4, 21%) or dead (n=56, 44%). Patients experiencing a poor outcome were older, had more comorbidities, and were more frequently discharged to a post-acute care facility than patients with either fair or good outcomes (all p <0.05). Costs per patient were $306,135 (SD $285,467) and total cohort costs totaled $38.1 million, for an estimated $3.5 million per one-year independently functioning survivor. The results of this single center study may not be applicable to other centers. Prolonged mechanical ventilation patients experience multiple transitions of care, resulting in extraordinary health care costs and persistent, profound disability. The optimism of surrogate decision makers should be balanced by discussions of these outcomes when considering a course of prolonged life support.
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影响因子：
7.2
作者：
DEYO, RA;CHERKIN, DC;CIOL, MA
通讯作者：
CIOL, MA
影响因子：
8.8
作者：
Cooper, LM;Linde-Zwirble, WT
通讯作者：
Linde-Zwirble, WT
影响因子：
9.6
作者：
Heyland, DK;Konopad, E;Gafni, A
通讯作者：
Gafni, A
影响因子：
38.9
作者：
Angus, DC;Carlet, J
通讯作者：
Carlet, J
影响因子：
8.8
作者：
Cox, Christopher E.;Carson, Shannon S.;Sanders, Gillian D.
通讯作者：
Sanders, Gillian D.