Prolonged mechanical ventilation: patterns of post-acute care and patient outcomes

项目总结/摘要 急性危重病存活但需要长时间机械通气（PMV，即机械通气）的患者 通气>14-21天）的数量迅速增长，有大量的急性后护理支出， 一年死亡率高达60%传统上，接受PMV的患者的急性后护理一直是 在同一家短期住院医院或转移到长期急性护理医院（LTCH）时提供， 这在很大程度上取决于短期住院实践。目前尚不清楚医院如何倾向于使用 接受PMV的患者的急性后护理的LTCH（或不）影响转移前提供者的行为 和患者的长期结果。支付改革，最初旨在丰富接受PMV的患者， LTCH（通过分层医疗保险报销模式）导致LTCH关闭，并可能发生变化 在多种护理环境（包括LTCH、短期住院医院和 专业护理设施（SNF，以前不常用于PMV护理）。因为某些练习模式 (e.g.,早期急性后设施转移，气管切开术的时间，喂食管，预先指示）发生在 PMV的发病，并可能决定部分患者是否经历PMV，我们将立即研究 做出此类决定的“上游”队列：PMV高风险人群（即机械通气 > 96小时，其中三分之一将继续需要PMV）。我们将结合先进的医疗服务， 新的计量经济学和定性方法，以实现以下具体目标：（1）确定趋势 以及10年内PMV高风险患者急性后设施使用变化的驱动因素 支付改革;（2）评估LTCH使用与（a）短期住院医生行为之间的关联 医院和（B）PMV高风险患者的长期结局;和（3）进行半结构化 对提供者和患者进行定性访谈，以确定LTCH使用的差异如何影响 急性期后护理计划和患者体验的方法。从这一混合产生的知识 方法方法对于告知临床实践（即通过改变提供者计划的方式， 选择急性期后护理的最佳地点）和未来政策（即，通过潜在地影响未来的支付改革 并确定其他急性后护理场所，如熟练的护理设施，是否应该成为目标， 质量报告法）。

PROJECT SUMMARY/ABSTRACT Patients who survive acute critical illness but require prolonged mechanical ventilation (PMV, i.e. mechanical ventilation >14-21 days) are growing rapidly in number, have large post-acute care expenditures, and experience a grim 60% 1-year mortality. Traditionally, post-acute care of patients receiving PMV has been provided either within the same short-stay hospital or on transfer to long-term acute care hospitals (LTCHs), depending in large part on short-stay hospital practice. It is unclear how a hospital’s tendency to use LTCHs (or not) for post-acute care of patients receiving PMV affects pre-transfer provider behaviors and long-term patient outcomes. Payment reforms, initially intended to enrich for patients receiving PMV at LTCHs (via a tiered Medicare reimbursement model), have led to LTCH closures and potentially also changes in admission and transfer criteria across multiple care settings, including LTCHs, short-stay hospitals, and skilled nursing facilities (SNFs, previously uncommonly used for PMV care). Because certain practice patterns (e.g., early post-acute facility transfer, timing of tracheostomy, feeding tubes, advance directives) occur prior to PMV onset and may determine in part whether a patient undergoes PMV, we will study the immediately ‘upstream’ cohort in whom such decisions are made: those at high risk for PMV (i.e. mechanically ventilated >96hrs, 1 in 3 of whom will go on to require PMV). We will apply a combination of advanced health services, novel econometric, and qualitative methods to accomplish the following specific aims: (1) Determine trends and drivers of variation in post-acute facility use among patients at high risk for PMV in the 10 years spanning payment reform; (2) Evaluate the association between LTCH use and (a) physician behavior at short-stay hospitals and (b) long-term outcomes of patients at high risk for PMV; and (3) Perform semi-structured qualitative interviews of providers and patients to determine how differences in LTCH use may impact approaches to post-acute care planning and patient experiences. The knowledge generated from this mixed methods approach will be critical to inform both clinical practice (i.e. by altering the way providers plan for and choose optimal sites of post-acute care) and future policy (i.e. by potentially shaping future payment reform and determining whether other sites of post-acute care, such as skilled nursing facilities, should be targets of quality reporting legislation).