近日，美国德克萨斯大学西南医学中心Rohan Khera小组，分析了再入院减少倡议的出院后急救和结局。相关论文于2020年1月15日发表在《英国医学杂志》上。

为了确定在急诊室或观察室接受治疗但在30天内未再次住院，符合国家再住院计划的患者是否会增加死亡风险，评估住院部、急诊部和观察病房的患者出院后急救利用率的时间趋势，研究组设计了一项回顾性队列研究。

研究组分析了美国2008-2016年的医疗保险索赔数据，参与者的年龄均在65岁及以上，因心力衰竭、急性心肌梗死或肺炎而入院，均纳入美国医院再入院减少计划。 

因心力衰竭而住院的患者有3772924例，急性心肌梗死1570113例，肺炎3131162例。心力衰竭患者出院后30天的总死亡率为8.7%，急性心肌梗死为7.3%，肺炎为8.4%。心力衰竭的风险调整死亡率每年增加0.05%，急性心肌梗死每年减少0.06%，肺炎则无显著变化。

具体来说，没有进行出院后急救的心力衰竭患者死亡率每年增加0.08%，超过心衰出院后死亡率的年绝对增长率，而观察室和急诊室的死亡率没有增加。在减少30天再入院率的同时，心力衰竭、急性心肌梗死和肺炎患者出院后超过30天再次住院观察和挂急诊的次数均有所增加。出院后30天的总急救利用率变化不显著。

总之，在整个研究期间只有心力衰竭患者死亡率增加，且这一增长是在政策出台之前，而在急诊室和观察病房中进行治疗的未住院患者死亡率无变化。在此期间，心力衰竭和肺炎患者出院后30天的整体急救利用率显著下降，但急性心肌梗死患者无明显下降。

附：英文原文

Title: Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort study of Medicare beneficiaries in the United States

Author: Rohan Khera, Yongfei Wang, Susannah M Bernheim, Zhenqiu Lin, Harlan M Krumholz

Issue&Volume: 2020/01/15

Abstract: 

Objectives To determine whether patients discharged after hospital admissions for conditions covered by national readmission programs who received care in emergency departments or observation units but were not readmitted within 30 days had an increased risk of death and to evaluate temporal trends in post-discharge acute care utilization in inpatient units, emergency departments, and observation units for these patients.

Design Retrospective cohort study.

Setting Medicare claims data for 2008-16 in the United States.

Participants Patients aged 65 or older admitted to hospital with heart failure, acute myocardial infarction, or pneumonia—conditions included in the US Hospital Readmissions Reduction Program.

Main outcome measures Post-discharge 30 day mortality according to patients’ 30 day acute care utilization; acute care utilization in inpatient and observation units and the emergency department during the 30 day and 31-90 day post-discharge period.

Results 3 772 924 hospital admissions for heart failure, 1 570 113 for acute myocardial infarction, and 3 131 162 for pneumonia occurred. The overall post-discharge 30 day mortality was 8.7% for heart failure, 7.3% for acute myocardial infarction, and 8.4% for pneumonia. Risk adjusted mortality increased annually by 0.05% (95% confidence interval 0.02% to 0.08%) for heart failure, decreased by 0.06% (−0.09% to −0.04%) for acute myocardial infarction, and did not significantly change for pneumonia. Specifically, mortality increased for patients with heart failure who did not utilize any post-discharge acute care, increasing at a rate of 0.08% (0.05% to 0.12%) per year, exceeding the overall absolute annual increase in post-discharge mortality in heart failure, without an increase in mortality in observation units or the emergency department. Concurrent with a reduction in 30 day readmission rates, stays for observation and visits to the emergency department increased across all three conditions during and beyond the 30 day post-discharge period. Overall 30 day post-acute care utilization did not change significantly.

Conclusions The only condition with increasing mortality through the study period was heart failure; the increase preceded the policy and was not present among patients who received emergency department or observation unit care without admission to hospital. During this period, the overall acute care utilization in the 30 days after discharge significantly decreased for heart failure and pneumonia, but not for acute myocardial infarction.

DOI: 10.1136/bmj.l6831

Source: https://www.bmj.com/content/368/bmj.l6831