医院因出院和住院死亡率而接受医学建议的出院协会。,JAMA Network Open

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医院因出院和住院死亡率而接受医学建议的出院协会。
JAMA Network Open ( IF 10.5 ) Pub Date : 2020-06-01 , DOI: 10.1001/jamanetworkopen.2020.6009
Sally Y Tan _{1,

2} , Jeremy Y Feng _{1,

3} , Cara Joyce ₄ , Jonathan Fisher ₁ , Arash Mostaghimi ₂

Affiliation

重要性住院再住院会增加支出，有时可能反映出患者护理不佳。因医疗建议（AMA）出院的患者属于弱势患者群体，可能有更高的再次入院风险。目的为了确定出院AMA与其他所有患者的再入院率和死亡率的可能性，确定与再入院相关的患者和医院水平因素，并量化其总体成本负担。设计，设置和参与者使用2014年全国再入学数据库，具有全国代表性的全额付费队列研究。符合条件的指数入院条件为2014年1月至2014年11月间出院的18岁及以上患者的非产科/新生儿住院治疗。如果缺少主要诊断，出院安排，住院时间或患者在住院期间死亡。分析了2018年1月至2018年6月之间的数据。暴露排放AMA和非AMA排放。主要结果和衡量指标30天全因再入院和医院内死亡率。结果共有1990万加权指数入场，其中1.5％导致了AMA出院。在AMA队列中，年龄在65岁以下的年轻人比例为85％，男性为63％，医疗补助或其他（包括无保险）覆盖范围为55％，收入最低的四分位数为39％。30天全因再入院率为21.0％，而AMA与非AMA出院为11.9％（P <.001），而30天住院死亡率分别为2.5％对5.6％（P <.001）。与非AMA患者相比，出院AMA的患者更有可能再次入住另一家医院（43.0％对23.9％； P <。001）。在所有30天的再次入院中，19.0％发生在AMA出院后的第一天，而非AMA患者为6.1％（P <.001）。在多变量回归中，与非AMA相比，AMA出院与调整后的入院调整后机率增加2.01（95％CI，1.97-2.05），而调整后入院几率降低0.80（95％CI，0.74-0.87）卸货。2014年，AMA出院后在全国范围内的再次入院占住院天数超过40万，总费用为8.22亿美元。结论和相关性AMA出院的人再次入院30天的几率较高，这对医疗保健系统造成了沉重的负担，而住院时间却更低。医院死亡率与非AMA患者相比。

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Association of Hospital Discharge Against Medical Advice With Readmission and In-Hospital Mortality.

Importance Hospital readmissions contribute to higher expenditures and may sometimes reflect suboptimal patient care. Individuals discharged against medical advice (AMA) are a vulnerable patient population and may have higher risk for readmission. Objectives To determine odds of readmission and mortality for patients discharged AMA vs all others, to characterize patient and hospital-level factors associated with readmissions, and to quantify their overall cost burden. Design, Setting, and Participants Nationally representative, all-payer cohort study using the 2014 National Readmissions Database. Eligible index admissions were nonobstetrical/newborn hospitalizations for patients 18 years and older discharged between January 2014 and November 2014. Admissions were excluded if there was a missing primary diagnosis, discharge disposition, length of stay, or if the patient died during that hospitalization. Data were analyzed between January 2018 and June 2018. Exposures Discharge AMA and non-AMA discharge. Main Outcomes and Measures Thirty-day all-cause readmission and in-hospital mortality rate. Results There were 19.9 million weighted index admissions, of which 1.5% resulted in an AMA discharge. Within the AMA cohort, 85% were younger than 65 years, 63% were male, 55% had Medicaid or other (including uninsured) coverage, and 39% were in the lowest income quartile. Thirty-day all-cause readmission was 21.0% vs 11.9% for AMA vs non-AMA discharge (P < .001), and 30-day in-hospital mortality was 2.5% vs 5.6% (P < .001), respectively. Individuals discharged AMA were more likely to be readmitted to a different hospital compared with non-AMA patients (43.0% vs 23.9%; P < .001). Of all 30-day readmissions, 19.0% occurred within the first day after AMA discharge vs 6.1% for non-AMA patients (P < .001). On multivariable regression, AMA discharge was associated with a 2.01 (95% CI, 1.97-2.05) increased adjusted odds of readmission and a 0.80 (95% CI, 0.74-0.87) decreased adjusted odds of in-hospital mortality compared with non-AMA discharge. Nationwide readmissions after AMA discharge accounted for more than 400 000 inpatient hospitalization days at a total cost of $822 million in 2014. Conclusions and Relevance Individuals discharged AMA have higher odds of 30-day readmission at significant cost to the health care system and lower in-hospital mortality rates compared with non-AMA patients. Patients discharged AMA are also more likely to be readmitted to different hospitals and to have earlier bounce-back readmissions, which may reflect dissatisfaction with their initial episode of care.

更新日期：2020-06-01

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