The Association Between Hospital Care Intensity and Surgical Outcomes in Medicare Patients
The Association Between Hospital Care Intensity and Surgical Outcomes in Medicare Patients
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DOI：
10.1001/jamasurg.2014.552
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发表时间：
2014-12-01
期刊：
影响因子：
16.9
通讯作者：
Ghaferi, Amir A.
中科院分区：
文献类型：
--
作者：
Sheetz, Kyle H.;Dimick, Justin B.;Ghaferi, Amir A.
美国各地医院的护理强度差异很大。付款人和政策制定者已成为重点，以促进质量，低成本，有效的healthcare.Objective评估是否增加医院护理强度（HCI）与改善的结果后，major surgery.Design，SETTING，AND PARTICIPANTS使用国家医疗保险数据在这项回顾性队列研究中，我们确定了706 520例患者在2544家医院谁经历了7个主要心血管，暴露HCI指数，这是通过达特茅斯医疗保健地图集验证和公开提供的。主要结果和措施风险和可靠性调整的死亡率，主要并发症和抢救失败率。结果医院护理强度变化10倍。与低HCI中心相比，高HCI医院的重大并发症发生率更高（风险比，1.04; 95%CI，1.03-1.05）。与低HCI医院相比，高HCI医院的抢救失败率降低（风险比，0.95; 95%CI，0.94-0.97）。使用多水平模型，在考虑患者合并症和医院资源后，HCI将医院之间的抢救失败率的差异降低了2.7%。在高HCI医院治疗的患者有较长的住院时间，更多的住院死亡，并降低临终关怀使用在过去2 years of life.CONCLUSIONS和相关性失败抢救率较低，在高护理强度的医院。相反，护理强度解释了一个非常小的比例的变化，在失败的抢救率在医院。
IMPORTANCE Hospitals' care intensity varies widely across the United States. Payers and policy makers have become focused on promoting quality, low-cost, efficient health care.OBJECTIVE To evaluate whether increased hospital care intensity (HCI) is associated with improved outcomes following major surgery.DESIGN, SETTING, AND PARTICIPANTS Using national Medicare data in this retrospective cohort study, we identified 706 520 patients at 2544 hospitals who underwent 1 of 7 major cardiovascular, orthopedic, or general surgical operations.EXPOSURE The HCI Index, which is validated and publicly available through the Dartmouth Atlas of Healthcare.MAIN OUTCOMES AND MEASURES Risk-and reliability-adjusted mortality, major complication, and failure-to-rescue rates.RESULTS Hospital care intensity varied 10-fold. High-HCI hospitals had greater rates of major complications when compared with low-HCI centers (risk ratio, 1.04; 95% CI, 1.03-1.05). There was a decrease in failure to rescue at high compared with low-HCI hospitals (risk ratio, 0.95; 95% CI, 0.94-0.97). Using multilevel-models, HCI reduced the variation in failure-to-rescue rates between hospitals by 2.7% after accounting for patient comorbidities and hospital resources. Patients treated at high-HCI hospitals had longer hospitalizations, more inpatient deaths, and lower hospice use during the last 2 years of life.CONCLUSIONS AND RELEVANCE Failure-to-rescue rates were lower at high-care intensity hospitals. Conversely, care intensity explains a very small proportion of variation in failure-to-rescue rates across hospitals.