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[JAMA最新论文]:轮转结束时住院医师换班增加住院患者病死率
2016年12月08日 时讯速递, 进展交流 评论数 1

Original Investigation

December 6, 2016

Association Between End-of-Rotation Resident Transition in Care and Mortality Among Hospitalized Patients

Joshua L. Denson, MDAshley Jensen, MPAHarry S. Saag, MDet al

JAMA. 2016;316(21):2204-2213. doi:10.1001/jama.2016.17424

Abstract

Importance 背景

Shift-to-shift transitions in care among house staff are associated with adverse events. However, the association between end-of-rotation transition (in which care of the patient is transferred) and adverse events is uncertain.

住院医师交接班伴随不良事件发生。然而,轮转结束时换班(负责患者治疗的医生改变)与不良事件的相关性并不确切。

Objective 目的

To examine the association of end-of-rotation house staff transitions with mortality among hospitalized patients.

验证轮转结束时住院医师换班与住院患者病死率的相关性。

Design, Setting, and Participants 设计,场景及研究者

Retrospective multicenter cohort study of patients admitted to internal medicine services (N = 230 701) at 10 university-affiliated US Veterans Health Administration hospitals (2008-2014).

对于2008-2014年间10所美国大学附属退伍军人医院内科收治的患者(N = 230701)进行的回顾性多中心队列研究。

Exposures 暴露

Transition patients (defined as those admitted prior to an end-of-rotation transition who died or were discharged within 7 days following transition) were stratified by type of transition (intern only, resident only, or intern + resident) and compared with all other discharges (control). An alternative analysis comparing admissions within 2 days before transition with admissions on the same 2 days 2 weeks later was also conducted.

将换班期患者(定义为轮转结束前收治且在换班7天内死亡或出院的患者)根据换班种类(仅有实习医生,仅有住院医生,或实习医生和住院医生)分层,并与其他出院患者(对照)进行比较。另外,对换班前2天内入院患者与2周后同样2天入院患者进行分析。

Main Outcomes and Measures 主要预后及指标

The primary outcome was in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and readmission rates. A difference-in-difference analysis assessed whether outcomes changed after the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations. Adjustments included age, sex, race/ethnicity, month, year, length of stay, comorbidities, and hospital.

主要预后指标为住院病死率。次要预后指标包括30天和90天病死率及再住院率。采用双重差分分析评价2011年美国毕业后医学教育评鉴委员会(ACGME)发布值班时间规定后预后是否改变。对年龄,性别,种族,月份,年份,住院日,并发症及医院进行校正。

Results 结果

Among 230 701 patient discharges (mean age, 65.6 years; men, 95.8%; median length of stay, 3.0 days), 25 938 intern-only, 26 456 resident-only, and 11 517 intern + resident end-of-rotation transitions occurred. Overall mortality was 2.18% in-hospital, 9.45% at 30 days, and 14.43% at 90 days. Adjusted hospital mortality was significantly greater in transition vs control patients for the intern-only group (3.5% vs 2.0%; odds ratio [OR], 1.12 [95% CI, 1.03-1.21]) and the intern + resident group (4.0% vs 2.1%; OR, 1.18 [95% CI, 1.06-1.33]), but not for the resident-only group (3.3% vs 2.0%; OR, 1.07 [95% CI, 0.99-1.16]). Adjusted 30-day and 90-day mortality rates were greater in all transition vs control comparisons (30-day mortality: intern-only group, 14.5% vs 8.8%, OR, 1.17 [95% CI, 1.13-1.22]; resident-only group, 13.8% vs 8.9%, OR, 1.11 [95% CI, 1.04-1.18]; intern + resident group, 15.5% vs 9.1%, OR, 1.21 [95% CI, 1.12-1.31]; 90-day mortality: intern-only group, 21.5% vs 13.5%, OR, 1.14 [95% CI, 1.10-1.19]; resident-only group, 20.9% vs 13.6%, OR, 1.10 [95% CI, 1.05-1.16]; intern + resident group, 22.8% vs 14.0%, OR, 1.17 [95% CI, 1.11-1.23]). Duty hour changes were associated with greater adjusted hospital mortality for transition patients in the intern-only group and intern + resident group than for controls (intern-only: OR, 1.11 [95% CI, 1.02-1.21]; intern + resident: OR, 1.17 [95% CI, 1.02-1.34]). The alternative analyses did not demonstrate any significant differences in mortality between transition and control groups.

在230 701名出院患者(平均年龄,65.6岁;男性,95.8%;中位住院日,3.0天)中,25 938名患者仅实习医生轮转结束换班,26 456名患者仅住院医生轮转结束换班,11 517名患者实习医生及住院医生均轮转结束换班。总体住院病死率为 2.18%,30天病死率9.45%,90天病死率14.43%。仅实习医生换班组患者(3.5% vs 2.0%,比数比[OR],1.12 [95% CI, 1.03-1.21])及实习医生和住院医生换班组患者 (4.0% vs 2.1%; OR, 1.18 [95% CI, 1.06-1.33])校正后住院病死率显著高于对照组,但仅住院医生换班组患者病死率无显著升高 (3.3% vs 2.0%; OR, 1.07 [95% CI, 0.99-1.16])。所有换班组患者校正后30天和90天病死率均高于对照组(30天病死率:仅实习医生换班组,14.5% vs 8.8%, OR, 1.17 [95% CI, 1.13-1.22];仅住院医生换班组,13.8% vs 8.9%, OR, 1.11 [95% CI, 1.04-1.18];实习医生和住院医生换班组,15.5% vs 9.1%, OR, 1.21 [95% CI, 1.12-1.31];90天病死率:仅实习医生换班组,21.5% vs 13.5%, OR, 1.14 [95% CI, 1.10-1.19];仅住院医生换班组,20.9% vs 13.6%, OR, 1.10 [95% CI, 1.05-1.16];实习医生和住院医生换班组,22.8% vs 14.0%, OR, 1.17 [95% CI, 1.11-1.23])。值班时间改变后,仅实习医生换班组以及实习医生和住院医生换班组校正后住院病死率显著高于对照组(仅实习医生换班组,OR, 1.11 [95% CI, 1.02-1.21];实习医生和住院医生换班组,OR, 1.17 [95% CI, 1.02-1.34])。其他分析并未显著换班组和对照组患者病死率存在显著差异。

Conclusions and Relevance 结论与意义

Among patients admitted to internal medicine services in 10 Veterans Affairs hospitals, end-of-rotation transition in care was associated with significantly higher in-hospital mortality in an unrestricted analysis that included most patients, but not in an alternative restricted analysis. The association was stronger following institution of ACGME duty hour regulations.

对于10所退伍军人医院内科收治的患者而言,包括多数患者的非限制性分析显示,轮转结束时住院医生换班伴随住院病死率升高,但限制性分析结果则不然。ACGME值班时间规定发布后这一相关性更显著。

 

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  1. hchangbao : 2016年12月08日21:11:54  -49楼

    有全文吗,求全文

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