The role of long term acute care hospitals in prolonged mechanical ventilation

描述（由申请人提供）：许多危重病患者在急性发作后存活，但持续器官衰竭，需要持续的生命支持和延长机械通气（PMV）的需要。PMV对卫生系统来说是一个非常大的财务和临床负担，PMV患者占所有重症监护室费用的近一半，一年死亡率接近50%。传统上，需要PMV的患者在短期住院期间接受了整个急性护理。然而，近年来，PMV的长期急性护理（LTAC）医院的使用急剧增加。LTAC是美国医院医疗中增长最快的部分，每年以12%的速度增长，仅在2004年就占医疗保险支出的31亿美元。尽管PMV患者的LTAC模型迅速扩展，但关于其临床有效性和对重症监护费用的影响仍存在重要问题。LTAC可能是PMV患者的具有成本效益的护理模式，可能会在不影响质量的情况下增加成本，甚至可能会对短期ICU中的持续护理产生负面影响。本申请的总体目标是研究LTAC在重症住院患者护理中的作用。我们将使用来自医疗保险受益人的国家索赔数据和工具变量方法进行观察性队列研究，以控制选择偏倚和不可测量的混杂因素。在目标一中，我们将研究LTAC对PMV患者的比较有效性，观察生存率和护理费用。在目标二中，我们将确定LTAC的临床和经济影响是否因患者诊断或LTAC的类型而异-独立与垂直整合（即“医院中的医院”）。在目标三中，我们将评估LTAC渗透对急性护理资源利用和结局的更广泛影响，测试LTAC可用性和利用率的变化是否与所有住院患者的资源利用和结局相关。这项研究将是对危重患者LTAC利用率的首次严格分析，并将为LTAC在呼吸衰竭和慢性危重病患者护理中的作用提供关键见解。公共卫生相关性：鉴于人口老龄化和重症监护的最新进展，需要PMV的患者数量将在未来几年增加。临床医生、政策制定者和公众对优化这一高风险、高成本人群的护理结构有着浓厚的兴趣。该项目将直接为有关长期急症护理医院和PMV患者护理的关键临床和卫生政策决策提供信息。

DESCRIPTION (provided by applicant): Many patients with critical illness survive the acute episode yet have persistent organ failures requiring ongoing life support and the need for prolonged mechanical ventilation (PMV). PMV is an extraordinarily large financial and clinical burden on the health system-patients with PMV account for nearly half of all intensive care unit costs, and one-year mortality approaches 50%. Traditionally, patients requiring PMV have received their entire episode of acute care within a short stay hospital. However, in recent years there has been a dramatic increase in the use of long-term acute care (LTAC) hospitals for PMV. LTACs are the fastest growing segment of hospital medicine in the United States, increasing at a rate of 12% per year and accounting for $3.1 billion in Medicare spending during 2004 alone. Despite the rapid expansion of the LTAC model for patients with PMV, essential questions remain about their clinical effectiveness and impact on the cost of intensive care. LTACs could be cost-effective model of care for patients with PMV, could raise costs without impacting quality, or may even negatively impact outcomes compared to continued care in a short stay ICU. The overall objective of this application is to study the role of LTACs in the care of critically ill hospitalized patients. We will perform an observational cohort study using national claims data from Medicare beneficiaries and an instrumental variable approach to control for selection bias and unmeasured confounding. In Aim One we will examine the comparative effectiveness of LTACs for patients with PMV, looking at both survival and costs of care. In Aim Two we will determine if the clinical and economic impact of LTACs varies by either patient diagnosis or the type of LTAC--free standing versus vertically integrated (i.e. "hospitals-within-a-hospital"). In Aim Three we will evaluate the broader impact of LTAC penetration on acute care resource utilization and outcome, testing whether variation in LTAC availability and utilization is associated with resource utilization and outcomes for all hospitalized patients. This study will be the first rigorous analysis of LTAC utilization in critically ill patients and will provide key insight into the role of LTACs in the care of patients with respiratory failure and chronic critical illness. PUBLIC HEALTH RELEVANCE: Given the aging of the population and recent advances in critical care, the number of patients requiring PMV will rise in the coming years. Clinicians, policy makers and public have a strong interest in optimizing the structures of care for this high-risk, high-cost population. This project will directly inform key clinical and health policy decisions about long-term acute care hospitals and the care of patients with PMV.