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

项目摘要/摘要 在急性危重病中存活但需要长时间机械通气(PMV，即机械通气)的患者 通风和GT；14-21天)数量快速增长，有大量的急性后护理支出，以及 经历了可怕的60%的一年死亡率。传统上，接受PMV的患者的急性后护理一直是 在同一家短期医院内或在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的做法。目前尚不清楚一家医院倾向于如何使用 接受PMV患者急性后护理的LTCHs(或非LTCHs)影响转院前提供者行为 以及患者的长期结果。支付改革，最初旨在丰富接受PMV治疗的患者 LTCH(通过分级医疗保险报销模式)已导致LTCH关闭，并可能也会发生变化 在多个护理环境中的入院和转院标准，包括长期护理中心、短期医院和 熟练的护理设施(SNF，以前不常用于PMV护理)。因为某些实践模式 (例如，急性后早期设施转移、气管切开术的时机、喂养管、提前指令)发生在 PMV发作，并可能部分确定患者是否经历PMV，我们将立即研究 做出此类决定的“上游”人群：PMV高危人群(即机械通风 &gt；96小时，其中三分之一的人将继续要求PMV)。我们将应用先进的卫生服务相结合， 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年间PMV高危患者急性后设施使用差异的驱动因素 支付改革；(2)评估使用LTCH与(A)医生短期行为之间的关联 医院和(B)PMV高危患者的长期结果；和(3)执行半结构化 对提供者和患者进行定性访谈，以确定使用LTCH的差异可能会如何影响 急性后护理计划和患者经验的方法。从这一混合中产生的知识 方法方法对于为临床实践提供信息(例如，通过改变提供商计划和 选择最佳的急性后护理地点)和未来的政策(即通过潜在地影响未来的支付改革 以及确定其他急性后护理场所，如熟练护理设施，是否应该成为目标 质量报告立法)。

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).