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

摘要 许多危重患者在急性发作中幸存下来，但仍有永久性器官 需要持续生命支持的故障和需要延长机械通气的情况 (PMV)。PMV对健康造成了极大的经济和临床负担 系统-PMV患者占所有重症监护病房成本的近一半，以及 一年的死亡率接近50%。传统上，需要PMV的患者会接受 他们在短期住院期间的整个急救过程。然而，近年来， 使用长期急性护理(LTAC)医院的人数急剧增加 对于PMV。LTAC是美国医院医学中增长最快的部分 各州，以每年12%的速度增长，占医疗保险的31亿美元 仅2004年一年的支出。尽管LTAC模式为患者提供了快速扩展 对于PMV，基本的问题仍然是关于其临床有效性和对 重症监护费用。LTAC可能是治疗慢性阻塞性肺疾病患者的经济有效的模式 PMV，可能会在不影响质量的情况下提高成本，甚至可能会产生负面影响 与短期ICU中持续护理的结果进行比较。这样做的总体目标是 建议研究LTAC在危重住院病人护理中的作用。 我们将使用联邦医疗保险的国家索赔数据进行观察性队列研究 受益者和工具变量方法来控制选择偏差和 难以捉摸的困惑。在目标一中，我们将检查以下各项的比较有效性 PMV患者的LTAC，同时考虑生存和护理成本。在目标二中 我们将确定LTAC的临床和经济影响是否因以下两种情况之一而变化 患者诊断或LTAC类型--自由站立与垂直整合(即 “医院中的医院”)。在目标三，我们将评估更广泛的影响 LTAC在急性护理资源利用和结局方面的渗透率，测试是否 LTAC可用性和利用率的变化与资源利用率和 所有住院患者的结果。这项研究将是第一次对 LTAC在危重患者中的应用，并将为了解LTAC在 LTAC在护理呼吸衰竭和慢性危重病患者中的作用。

Abstract 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 proposal 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 umeasured confounding. In Aim One we will examine the comparitive effectiveness of LTACs for patients with PMV, looking at both survival and costs of care. In Aim Two we will 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 chonic critical illness.