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

描述(申请人提供)：许多重症患者在急性发作后存活下来，但仍有持续性器官衰竭，需要持续的生命支持和延长机械通气(PMV)的需要。PMV给卫生系统造成了极大的财政和临床负担--PMV患者占所有重症监护病房费用的近一半，一年死亡率接近50%。传统上，需要PMV的患者会在短期住院期间接受整个急诊护理。然而，近年来，长期急性护理(LTAC)医院对PMV的使用急剧增加。LTAC是美国医院医疗中增长最快的部分，以每年12%的速度增长，仅在2004年就占到了31亿美元的医疗保险支出。尽管PMV患者的LTAC模式迅速扩展，但其临床有效性和对重症监护费用的影响仍存在基本问题。对于PMV患者，LTAC可能是一种具有成本效益的护理模式，可以在不影响质量的情况下提高成本，甚至与在短期ICU继续护理相比，甚至可能对结果产生负面影响。这项应用的总体目标是研究LTAC在重症住院患者护理中的作用。我们将使用联邦医疗保险受益人的全国索赔数据和工具变量方法进行观察性队列研究，以控制选择偏差和未测量的混杂。在第一个目标中，我们将从存活率和护理成本两个方面考察长期胸腔积液疗法对PMV患者的比较效果。在第二个目标中，我们将确定LTAC的临床和经济影响是否因患者的诊断或LTAC的类型而异--独立与垂直整合(即“医院中的医院”)。在第三个目标中，我们将评估LTAC渗透率对急性护理资源利用和结果的更广泛影响，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果相关。这项研究将是对LTAC在危重患者中使用情况的第一次严格分析，并将为LTAC在治疗呼吸衰竭和慢性危重疾病患者中的作用提供关键的见解。公共卫生相关性：鉴于人口老龄化和最近在重症监护方面的进展，需要PMV的患者数量在未来几年将会上升。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性护理医院和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.