論文No1328
Outcomes after Rehospitalization at the Same Hospital or a Different Hospital Following Critical Illness
May Hua, Michelle Ng Gong, Andrea Miltiades, Hannah Wunsch
AJRCCM, Vol. 195, No. 11 | Jun 01, pp. 1486–1493, 2017
＜背景＞
人工呼吸管理をうけているICU患者は早期再入院のリスクが高い。
医療的な複雑性のあることを考えると、ケアの連続性が失われると再入院中のアウトカムに悪い影響が出るかもしれない。
＜目的＞
ICU滞在後の再入院を別の病院でした場合と同じ病院でした場合で、アウトカムが異なるかを調べる。
＜方法＞
2008年から2013年までに人工呼吸器装着した患者が30日以内にニューヨーク州の病院に再入院した場合を後ろ向きにコホート研究で行った。
＜結果＞
別の病院の再入院の頻度、死亡率、入院期間、費用を調べた。
人工呼吸器装着歴のあるICU患者で30日以内に再入院した26947名のうち、8443名(31.3%)は別の病院に入院していた。
別の病院に入院した場合、死亡率は13.7% vs 11.1%で高かった(adjusted rate ratio [aRR], 1.11; 95% confidence interval [CI], 1.03–1.20; P = 0.009)。
別の病院に入院した患者は入院期間が短く(aRR, 0.80; 95% CI, 0.70–0.92; P = 0.001)、コストも少なかった(adjusted mean difference, −$9,632.73; 95% CI, −$16,387.60 to −$2,877.88; P = 0.005)。
別の病院に入院して生存していた患者は入院期間が若干長く(aRR, 1.06; 95% CI, 1.01–1.11; P = 0.009) 、入院コストが高かった(adjusted mean difference, $1,665.34; 95% CI, $602.12–$2,728.56; P = 0.002)。
＜感想＞
人工呼吸器装着患者は退院後約１/３が別の病院に入院していたようです。ケアの不連続性が死亡率上昇と関連していたようです。
Rationale: Intensive care unit (ICU) patients who receive mechanical ventilation are at high risk for early rehospitalization. Given the medical complexity of these patients, a lack of continuity of care may adversely affect their outcomes during rehospitalization.
Objectives: To determine whether outcomes differ for patients who are rehospitalized at a different hospital versus the hospital of their index ICU stay.
Methods: We conducted a retrospective cohort study of mechanically ventilated ICU patients rehospitalized within 30 days in New York State hospitals between 2008 and 2013.
Measurements and Main Results: We measured frequency of rehospitalization at a different hospital, mortality, length of stay, and costs during rehospitalization. Of 26,947 mechanically ventilated ICU patients rehospitalized within 30 days of discharge, 8,443 (31.3%) were rehospitalized at a different hospital than that of the index ICU stay. For patients at a different hospital, 13.7% died during rehospitalization versus 11.1% who died at the index hospital (adjusted rate ratio [aRR], 1.11; 95% confidence interval [CI], 1.03–1.20; P = 0.009). Patients who died at a different hospital had shorter length of stay (aRR, 0.80; 95% CI, 0.70–0.92; P = 0.001) and decreased costs (adjusted mean difference, −$9,632.73; 95% CI, −$16,387.60 to −$2,877.88; P = 0.005), whereas survivors of rehospitalization at a different hospital had a modest increase in length of stay (aRR, 1.06; 95% CI, 1.01–1.11; P = 0.009) and increased costs of care (adjusted mean difference, $1,665.34; 95% CI, $602.12–$2,728.56; P = 0.002).
Conclusions: Almost one-third of mechanically ventilated critically ill patients were rehospitalized at a different hospital than that of the index ICU stay. This care discontinuity was associated with increased mortality.