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【社会人文】到不同医院再住院费用增加结果未
约有1/4再次住院的患者没有选择他们首次入院的医院，在何种程度上与营利性医院、死亡率相关，目前还不清楚。
为了研究Medicare医保体系患者30天内在不同医院再住院的预测因子和费用花费情况，美国威斯康星大学医学院的Amy J.H. Kind等做了一个队列研究。他们研究了2005年11月到2006年间74564名出院后再住院的患者，评估了他们30天在不同医院再住院、经济花费情况，以及30天内的死亡情况。
结果有16622名患者(22%)在不同的医院再住院，引起患者在不同医院再住院的影响因子包括营利性医院的住院指数、主要的医学院附属医院、小医院和Medicare规定的残疾。与第二次住院仍住同一家医院的患者相比，到不同医院再住院的患者30天总花费明显增加，每位患者平均多花1308美元，P<0.001;但他们之间30天死亡率却无显著差异。
从以上结果可以看出，Medicare患者选择在不同医院再住院的情况非常普遍，最先在营利性医院住院的患者尤其如此，由此带来费用增加，死亡率却并没有降低。
Ann Intern Med. 2010;153:718-727. 编译者：陈照奇
http://www.91sqs.com/3193/viewspace-64527.html
Editorial
Defragmenting Care
Stephen F. Jencks, MD, MPH
+ Author Affiliations
From Baltimore, MD 21210.
Rehospitalizations that occur soon after hospital discharge are drawing increasing attention. About 2.5 million Medicare beneficiaries and about 2 million other patients are rehospitalized within 30 days of discharge, with total hospital costs (not including physician services) of about $44 billion (1; Steiner C, Jiang J. Personal communication). From the perspectives of payers, purchasers, and policymakers, avoidable rehospitalizations represent massive and remediable waste. However, most rehospitalization is the result of clinical deterioration, occurs emergently, and is often necessary by the time the patient reaches the emergency department. Some emergency department visits might be prevented from turning into hospitalizations. However, compelling evidence from a series of controlled studies (2–4), in which interventions to improve the transition from hospital to posthospital care have reduced rehospitalizations by 30% to 50%, suggests that the rehospitalization problem represents a failure of those transitions rather than willful overuse of hospital services. It is a symptom of fragmented care.
Most clinicians easily see how these failures happen. When I ask clinicians to grade the discharge that followed the last hospitalization of a friend or family member, they give few As. My colleagues and I reported (1) that half of Medicare patients who were rehospitalized within 30 days of a medical discharge to the community had not seen a physician between discharge and rehospitalization, a finding that most clinicians find plausible. Ongoing studies provide further evidence that practitioners see rehospitalization as a clinical rather than a utilization issue. For example, almost 1000 hospitals have signed up for the Society of Hospital Medicine's Project BOOST (5) and the American College of Cardiology's Hospital-to-Home project, hospital-based programs that are intended to reduce rehospitalizations. Such enthusiasm would be unlikely if clinicians saw these programs as utilization control.
The Patient Protection and Affordable Care Act (7) creates Medicare payment penalties, starting in 2012, for hospitals with higher-than-expected rates of rehospitalization among patients they discharge. Although federal rules will determine the final shape of this penalty, the legislation has clearly energized attention to rehospitalizations. Hospitals are, however, only 1 component of a fragmented system that must pull together to control rehospitalization. For years, poor in-hospital care was the assumed culprit in preventable rehospitalization, and the Medicare Peer Review Organizations were mandated to review the medical records of index hospitalizations that were followed by early rehospitalization. This process did not prove fruitful, and Weissman and colleagues later showed that rehospitalization was an unreliable indicator of inpatient quality problems.
Read in this context, Kind and colleagues' report in this issue (9) is a story about a fragmented system. Their study compares hospitals whose rehospitalized patients returned to the discharging hospital with those whose patients went elsewhere. Data from fragmented systems are inherently challenging to interpret because of the noise that fragmentation superimposes on whatever underlying patterns may exist. Kind and colleagues found that patients discharged from investor-owned hospitals were more likely to be rehospitalized elsewhere than those discharged from nonprofit hospitals, and they speculate on possible profit motives. However, this speculation suggests a degree of coherent, planned behavior that would be remarkable in such a chaotic system. In addition, because the predominant reasons for rehospitalization were medical, patients probably presented to emergency departments in acute distress. Although planned diversions of undesired emergency patients can occur, a filled bed generally represents positive cash flow, particularly because all study patients had Medicare. Diverting them would not have been a good business decision for the hospital, particularly because the penalties for excessive rehospitalizations were only a rumor when the study patients received care. A simpler explanation is that patients in acute distress go to the nearest hospital, which is often not the discharging hospital. Data available to the authors do not allow a confident determination of whether profit motives or geography drove these findings.
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作者:admin@医学,生命科学 2010-12-29 11:42
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