Patient Outcomes After Hospital Discharge to Home With Home Health Care vs to a Skilled Nursing Facility
Patient Outcomes After Hospital Discharge to Home With Home Health Care vs to a Skilled Nursing Facility
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DOI：
10.1001/jamainternmed.2018.7998
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发表时间：
2019-05-01
影响因子：
39
通讯作者：
Konetzka, Tamara
中科院分区：
文献类型：
--
作者：
Werner, Rachel M.;Coe, Norma B.;Konetzka, Tamara
在美国，急性期后护理的使用很常见，而且费用很高，但急性期后护理环境的选择是否重要还存在很大的不确定性。了解这些权衡是特别重要的，因为新的替代支付模式推动患者向低成本的设置为care. ObjectiveTo调查患者的结果和医疗保险费用出院回家与家庭医疗保健与出院到一个熟练的护理设施的关联。一项回顾性队列研究使用了来自短期急性-2010年1月1日至2016年12月31日期间，美国医疗保健医院和熟练护理机构和家庭健康评估数据，关于从医院出院到家庭健康护理或熟练护理机构的Medicare受益人。为了解决治疗选择的内在性，工具变量方法使用受益人的家庭邮政编码与最近的家庭卫生机构和最近的熟练护理设施之间的差异距离作为instrument.EXPOSURES接收急性期后护理在家vs在熟练护理设施.主要结果和指标出院后30天内再次入院，出院后30天内死亡，急性期后护理事件期间功能状态的改善，以及急性期后护理的医疗保险支付和60天事件的总支付。（62.2%为女性，37.8%为男性;平均[SD]年龄，80.5 [7.9]岁）在研究期间出院回家接受家庭医疗保健（38.8%）或到专业护理机构（61.2%）。出院回家与30天再入院率比出院到专业护理机构高5.6个百分点相关（95%CI，0.8-10.3; P= 0.02）。30天死亡率（-2.0个百分点; 95% CI，0.8-10.3; P= 0.12）或功能状态改善（-1.9个百分点; 95% CI，-12.0至8.2; P= 0.71）无显著差异。出院回家的患者的急性期后护理的医疗保险支付显著低于出院到专业护理机构的患者（-5384美元; 95%CI，-6932至-3837美元; P
IMPORTANCE Use of postacute care is common and costly in the United States, but there is significant uncertainty about whether the choice of postacute care setting matters. Understanding these tradeoffs is particularly important as new alternative payment models push patients toward lower-cost settings for care.OBJECTIVE To investigate the association of patient outcomes and Medicare costs of discharge to home with home health care vs discharge to a skilled nursing facility.DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study used Medicare claims data from short-term acute-care hospitals in the United States and skilled nursing facility and home health assessment data from January 1, 2010, to December 31, 2016, on Medicare beneficiaries who were discharged from the hospital to home with home health care or to a skilled nursing facility. To address the endogeneity of treatment choice, an instrumental variables approach used the differential distance between the beneficiary's home zip code and the closest home health agency and the closest skilled nursing facility as an instrument.EXPOSURES Receipt of postacute care at home vs in a skilled nursing facility.MAIN OUTCOMES AND MEASURES Readmission within 30 days of hospital discharge, death within 30 days of hospital discharge, improvement in functional status during the postacute care episode, and Medicare payment for postacute care and total payment for the 60-day episode.RESULTS A total of 17 235 854 hospitalizations (62.2% women and 37.8% men; mean [SD] age, 80.5 [7.9] years) were discharged either to home with home health care (38.8%) or to a skilled nursing facility (61.2%) during the study period. Discharge to home was associated with a 5.6-percentage point higher rate of readmission at 30 days compared with discharge to a skilled nursing facility (95% CI, 0.8-10.3; P=.02). There were no significant differences in 30-day mortality rates (-2.0 percentage points; 95% CI, 0.8-10.3; P=.12) or improved functional status (-1.9 percentage points; 95% CI, -12.0 to 8.2; P=.71). Medicare payment for postacute care was significantly lower for those discharged to home compared with those discharged to a skilled nursing facility (-$5384; 95% CI, -$6932 to -$3837; P