背景:在紧急情况下入院的老年人往往住院时间较长,结果恶化,增加医疗保健费用,减少床的可用性。越来越多的证据表明,他们问题的生物心理社会复杂性,其中包括认知障碍,抑郁症,焦虑,多种医学疾病,以及由于功能依赖而产生的护理需求,通过降低医疗效率和更难以规划出院后护理来延长住院时间.我们旨在评估在HOME研究中使用主动综合咨询-联络精神病学(PICLP)增强老年住院患者护理的效果。我们先前已经描述了患者和临床医生报告的PICLP的益处。在这篇文章中,我们报告了PICLP强化护理的有效性和成本效益,与单纯的常规护理相比,减少住院时间。
方法:我们做了一个平行组,多中心,在英国三家急性综合医院的24个病房进行的随机对照试验。如果患者年龄在65岁或以上,则有资格参加,在紧急情况下入院,预计从登记之日起至少2天住院。通过使用医院分层的数据库软件算法,以1:1的比例将参与者随机分配到PICLP或常规护理中,性别,和年龄,和随机选择的块大小以确保分配隐藏。PICLP临床医生(由协助临床医生支持的咨询联络精神科医生)对患者的问题进行了积极的生物心理社会评估,然后作为病房团队的综合成员提供以出院为重点的护理。主要结果是在随机分组后30天内作为住院患者花费的时间(在索引入院和任何紧急再入院期间)。次要结果是指标入院总长度的出院率;出院目的地;随机分配后30天截断的指标入院长度;急诊再入院次数,在急性综合医院住院的天数,以及随机分配后一年的死亡率;患者的住院经历;他们对住院时间长短的看法;焦虑(广泛性焦虑症-2);抑郁(患者健康问卷-2);认知功能(蒙特利尔认知评估-电话版);独立功能(日常生活活动的Barthel指数);与健康相关的生活质量(五级EuroQol五维生活质量问卷);统计学家和数据收集者被掩盖了治疗分配;参与者和病房工作人员不能。分析是意向治疗。该试验有一个患者和公众参与小组,并在ISRTCN注册(ISRCTN86120296)。
结果:2744名参与者(1399[51·0%]男性和1345[49·0%]女性)在2018年5月2日至2020年3月5日之间登记;1373人被分配给PICLP,1371人被分配给常规护理。参与者的平均年龄为82·3岁(SD8·2),2565名(93·5%)参与者为白人。随机分组后30天(对2710名[98·8%]参与者进行分析)的平均住院时间为11·37天(SD8·74)和11·85天(SD9·00)。常规护理;调整平均差异-0·45(95%CI-11至0·21;p=0·18)。次要结局的唯一统计学和临床上显着差异是出院率,与PICLP相比高8.5%(比率比1·09[95%CI1·00至1·17];p=0·042)-在停留超过2周的患者中差异最明显。与平时护理相比,据估计,PICLP在1个月和3个月内具有适度的成本节约和成本效益,但不是12个月。无干预相关严重不良事件发生。
结论:这是第一个PICLP的随机对照试验。PICLP在老年住院患者和病房工作人员中具有增强医疗保健的经验。这也可能在短期内节省成本。尽管该试验没有提供强有力的证据表明PICLP减少了住院时间,它确实支持并告知其未来的发展和评估。
背景:英国国立卫生与护理研究所。
BACKGROUND: Older people admitted to hospital in an emergency often have prolonged inpatient stays that worsen their outcomes, increase health-care costs, and reduce bed availability. Growing evidence suggests that the biopsychosocial complexity of their problems, which include cognitive impairment, depression, anxiety, multiple medical illnesses, and care needs resulting from functional dependency, prolongs hospital stays by making medical treatment less efficient and the planning of post-discharge care more difficult. We aimed to assess the effects of enhancing older
inpatients\' care with Proactive Integrated Consultation-Liaison Psychiatry (PICLP) in The HOME Study. We have previously described the benefits of PICLP reported by patients and clinicians. In this Article, we report the effectiveness and cost-effectiveness of PICLP-enhanced care, compared with usual care alone, in reducing time in hospital.
METHODS: We did a parallel-group, multicentre, randomised controlled trial in 24 medical wards of three English acute general hospitals. Patients were eligible to take part if they were 65 years or older, had been admitted in an emergency, and were expected to remain in hospital for at least 2 days from the time of enrolment. Participants were randomly allocated to PICLP or usual care in a 1:1 ratio by a database software algorithm that used stratification by hospital, sex, and age, and randomly selected block sizes to ensure allocation concealment. PICLP clinicians (consultation-liaison psychiatrists supported by assisting clinicians) made proactive biopsychosocial assessments of patients\' problems, then delivered discharge-focused care as integrated members of ward teams. The primary outcome was time spent as an inpatient (during the index admission and any emergency readmissions) in the 30 days post-randomisation. Secondary outcomes were the rate of discharge from hospital for the total length of the index admission; discharge destination; the length of the index admission after random allocation truncated at 30 days; the number of emergency readmissions to hospital, the number of days spent as an inpatient in an acute general hospital, and the rate of death in the year after random allocation; the patient\'s experience of the hospital stay; their view on the length of the hospital stay; anxiety (Generalized Anxiety Disorder-2); depression (Patient Health Questionnaire-2); cognitive function (Montreal Cognitive Assessment-Telephone version); independent functioning (Barthel Index of Activities of Daily Living); health-related quality of life (five-level EuroQol five-dimension questionnaire); and overall quality of life. Statisticians and data collectors were masked to treatment allocation; participants and ward staff could not be. Analyses were intention-to-treat. The trial had a patient and public involvement panel and was registered with ISRTCN (ISRCTN86120296).
RESULTS: 2744 participants (1399 [51·0%] male and 1345 [49·0%] female) were enrolled between May 2, 2018, and March 5, 2020; 1373 were allocated to PICLP and 1371 to usual care. Participants\' mean age was 82·3 years (SD 8·2) and 2565 (93·5%) participants were White. The mean time spent in hospital in the 30 days post-randomisation (analysed for 2710 [98·8%] participants) was 11·37 days (SD 8·74) with PICLP and 11·85 days (SD 9·00) with usual care; adjusted mean difference -0·45 (95% CI -1·11 to 0·21; p=0·18). The only statistically and clinically significant difference in secondary outcomes was the rate of discharge, which was 8.5% higher (rate ratio 1·09 [95% CI 1·00 to 1·17]; p=0·042) with PICLP-a difference most apparent in patients who stayed for more than 2 weeks. Compared with usual care, PICLP was estimated to be modestly cost-saving and cost-effective over 1 and 3, but not 12, months. No intervention-related serious adverse events occurred.
CONCLUSIONS: This is the first randomised controlled trial of PICLP. PICLP is experienced by older medical
inpatients and ward staff as enhancing medical care. It is also likely to be cost-saving in the short-term. Although the trial does not provide strong evidence that PICLP reduces time in hospital, it does support and inform its future development and evaluation.
BACKGROUND: UK National Institute for Health and Care Research.