老年患者护理模式喜忧参半

《美国医学会杂志-内科学》4月22日在线发表在的一项单中心队列研究显示，与标准护理相比，老年住院患者急性护理(ACE)流动模式可减少患者不良事件发生率和缩短住院时间，但不能减少30天再住院率或改善患者功能状态(2013 April 22 [doi:10.1001/jamainternmed.2013.478])。

纽约西奈山医学中心老年医学和姑息医学部的William W. Hung博士及其同事报告称，老年患者流动急性护理(MACE)计划在某些关键方面似乎可改善这类脆弱老年人群良好结局。但与常规护理相比，MACE计划并不能改善患者功能状态、降低30天再住院率、出院后30天内急诊率以及专业护理机构转院率。

研究者指出，上世纪90年代引入的ACE病房目前已被广泛视为老年住院患者护理典范模式。该模式包括环境优良的专门病房，配备包括老年病医生在内的多学科医护人员，并特别重视出院计划和避免不良事件。但由于受到费用、人员和场地等主要条件的限制，这类病房并没有在各个医院得到广泛推广。

相比之下，MACE模式不需要专门的实体ACE病房。这种流动性模式只需老年病医生、社会工作者和临床护理专家等多学科团队对入住医院任何病区的老年患者提供护理。与ACE模式相比，MACE更加关注减少住院风险、改善与门诊实践的协调以及出院计划。

研究者开展的这项为期3年的前瞻性队列研究，评估了173例入住该医学中心接受MACE服务的≥75岁老年患者以及同期173例接受常规护理服务的对照患者的情况，以确定MACE能否改善患者结局。

两组患者在年龄、初始诊断和独立行走能力方面相匹配。两组患者平均年龄均约85岁，约76%为女性，56%为白人，35%为医疗补助保险覆盖者，小于1/3的患者可独立行走。

主要结局指标为出院后30天内再住院率。结果显示，两组患者该指标未见显著差异：MACE和常规护理患者再住院率分别为15.4%和22.4%。同样，两组患者出院后30天内再住院和急诊复合率也未见显著差异，MACE和常规护理组分别为20.8%和25.6%。30天功能状态也未见差异，两组患者完成基本日常生活活动能力的两项独立评估平均评分相似。此外，通过包含10个项目的患者报告结局评测信息系统(PROMIS)评价的患者30天总体健康状态，也未见组间显著差异。

然而，在诸如跌倒、需要限制和导管相关尿道感染等院内不良事件发生率方面，MACE组(9.5%)明显低于常规护理组(17.0%)。

校正后MACE组平均住院时间比常规护理组减少0.8天。但两组患者出院目的地相似，MACE组和常规护理组需要转入专业护理机构比例分别为24.9%和22.5%。

MACE组更多患者(92.2%)报告医护人员与他们讨论出院后的护理问题，而常规护理组相对较少(67.6%)。护理过渡评估-3(CTM-3)结果显示，MACE组对护理满意度高于常规护理组，但医院消费者对医疗服务提供方评价调查(HCAHPS)结果未见组间差异。

研究者指出，该研究可能存在选择性偏倚的局限性，因为MACE组患者还在老年诊所而非普通诊所接受了初级保健。此外，研究人员在查阅两组患者病历评估不良事件时，也没采取盲法。

研究者总结认为，基于医院采取ACE病房模式的限制，MACE “或许是一种可行的替代模式，因为该模式可完全整合到医院工作流程中，而无需设置专门病房。”

该研究由西奈山医学中心John A. Hartford卓越中心和Claude D. Pepper老年自立中心资助。Hung博士报告无利益冲突，他的一位同事报告与美国衰老研究基金会等多家机构和公司存在经济利益关联。

随刊述评：限制老年患者综合性护理的障碍

耶鲁大学的Lisa M. Walke 博士和 Mary E. Tinetti博士评论称，影响采纳MACE等老年护理协调模式的最重要障碍是医生习惯于仅对患者健康问题负责，而且仅局限于特定科室。其他障碍还包括缺少提供这类护理的老年医学专家、住院和门诊护理之间信息共享的数据基础设施以及对创立类似完全整合模式的经济激励措施。他们认为：“事实上，目前按病种服务付费方式阻碍了一体化护理模式的推广。”

评论者指出，幸运的是，医疗改革有可能鼓励护理模式由松散割裂型向以患者为中心的整合型转变，尤其是针对最为复杂的老年患者的护理(JAMA Intern. Med. 2013 April 22 [doi:10.1001/jamainternmed.2013.493])。

Walke博士和 Tinetti博士均报告无利益冲突。

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By: MARY ANN MOON, Internal Medicine News Digital Network

A mobile version of the Acute Care for Elderly inpatient care model reduced the rate of adverse events and shortened hospital stays, but it didn’t reduce 30-day readmission rates or improve patients’ functional status more than standard care did, according to a single-center cohort study.

The Mobile Acute Care for the Elderly (MACE) program at Mount Sinai Medical Center, New York, thus appears to promote better outcomes in some key areas "for this vulnerable older adult population," said Dr. William W. Hung of the department of geriatrics and palliative medicine at Mount Sinai and his associates in a study published online April 22 in JAMA Internal Medicine.

However, compared with usual care, the MACE program did not improve patients’ functional status, reduce 30-day readmission rates, decrease visits to the emergency department within 30 days of hospital discharge, or decrease rates of discharge to a skilled nursing facility, the investigators noted.

Introduced in the 1990s, the Acute Care for Elderly unit is "widely accepted as a prototype model to provide inpatient care for older adults," the study authors noted. The model includes a designated hospital unit with a specially designed environment, interdisciplinary caregivers including geriatricians, and particular attention to discharge planning and the avoidance of adverse events.

However, such units "have not been widely disseminated across institutions, particularly because of barriers to initial setup, including costs, staffing, and space needs," the investigators added.

The MACE model delivers care without requiring a dedicated, physical ACE unit.

This mobile approach allows an interdisciplinary team of geriatricians, social workers, and clinical nurse specialists to care for elderly patients admitted to any unit in the hospital. As with the ACE model, the MACE model focuses on reducing the risks of hospitalization, improving coordination with outpatient practice, and discharge planning.

Dr. Hung and his colleagues conducted a 3-year prospective cohort study to determine whether MACE was associated with improved outcomes. They assessed 173 patients aged 75 years and older who received MACE service when they were admitted to the medical center, and 173 control subjects admitted to the general inpatient medical service during the same period.

The two groups were matched for age, primary diagnosis, and ability to ambulate independently. The mean age of both groups was approximately 85 years; approximately 76% of patients were women, 56% were white, and 35% were Medicaid beneficiaries. Fewer than one-third of both groups were able to ambulate independently.

The primary outcome measure was readmission within 30 days of hospital discharge. On that measure, there was no significant difference between the two groups: 15.4% of the patients in the MACE service required readmission, as did 22.4% of the usual-care group, the researchers said.

Similarly, combined rates of readmission plus emergency department visits within 30 days did not differ significantly, at 20.8% for the MACE service and 25.6% for usual care.

Functional status at 30 days also did not differ. Mean scores were similar between the MACE patients and the usual-care patients on two separate measures of the ability to perform basic activities of daily living.

Similarly, overall health status at 30 days, as measured using the Patient Reported Outcomes Measurement Information Systems (PROMIS) 10-item instrument, was not significantly different between the two study groups.

However, the rate of in-hospital adverse events such as falls, bed sores, the need for restraints, and catheter-associated urinary tract infections was significantly lower in the MACE group (9.5%) than in the usual-care group (17.0%).

The adjusted mean length of stay was 0.8 days shorter for the MACE group than for the usual-care group. But discharge destination was similar between the two groups, with 24.9% of the MACE group and 22.5% of the usual-care group requiring discharge to a skilled nursing facility.

Patients in the MACE service were much more likely to report that their caregivers discussed post-discharge care with them (92.2%), compared with those in the usual-care group (67.6%).

Patient satisfaction with care was greater with the MACE service than with usual care on one instrument, the three-item Care Transition Measure. But it was no different on another instrument, the Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS).

The study may have been subject to selection bias, the investigators noted, because the patients in the MACE service were also receiving their primary care at a geriatric-based practice rather than in a general practice. Also, the investigator who reviewed the medical records for adverse events was not blinded to the patients’ group assignment.

Given the constraints that limit hospitals’ adoption of the ACE unit model, the MACE model "may be a viable alternative, because it can be seamlessly integrated in a hospital’s work flow without the requirement for a dedicated unit," the investigators concluded.

This study was supported by the John A. Hartford Center of Excellence and the Claude D. Pepper Older Americans Independence Center at Mount Sinai. Dr. Hung reported no financial conflicts of interest; one of his associates reported ties to the American Federation for Aging Research, FAIR Health, the U.S. Food and Drug Administration, Medtronic, the National Institute on Aging, and the Pew Charitable Trusts.

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Barriers block integrated geriatric care

The most important barrier to adopting coordinated models of geriatric care such as the MACE model is that it demands change from physicians who "are used to taking responsibility for only a subset of a patient’s health issues, and then only in specific settings," said Dr. Lisa M. Walke and Dr. Mary E. Tinetti.

Other obstacles include the paucity of geriatric specialists to provide this type of care, the lack of data infrastructure for sharing information across inpatient and outpatient sites of care, and the lack of a financial incentive to create such a fully integrated model. "In fact, the current disease-based fee-for-service payment structure creates a disincentive for streamlining care," they said.

Fortunately, health care reform should "encourage a shift from episodic, segmented care toward integrated patient-centered care ... even for our most complex older patients," they said.

Dr. Walke and Dr. Tinetti are in the division of geriatrics at Yale University, New Haven, Conn. Dr. Tinetti is also in the department of chronic disease epidemiology at Yale. They reported no financial conflicts of interest. These remarks were taken from their invited commentary accompanying Dr. Hung’s report (JAMA Intern. Med. 2013 April 22 [doi:10.1001/jamainternmed.2013.493]).