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Background
Since 1998 when the Bureau of National Health Insurance (NHI) launched the Integrated Delivery System (IDS) for ventilator-dependent patients, respiratory care services have been paid by capitation and respiratory care wards have increased from 1,046 beds in 2001 to 3,256 beds in October 2003, and then to 4,511 beds in November 2005. The number of holders of IC Card for Severe Illness (Long-term Ventilator Dependence) increased from 6,111 in January 1998 to 25,805 in August 2003, or 3.2 times growth. Hence, NHI adopted co-payment and capitation, and in 2004 NHI launched the Respiratory Care Ward (RCW) Quality Assessment and Rating System. Medical services provided in respiratory care wards are likely to change considerably in the face of a payment system reform. Several papers on the profile and care quality of respiratory care wards were published in the United States after 1985 but none in Taiwan. In this study, we shall analyze the outcome of respiratory care provided for ventilator-dependent patients under the new system and assesses the effect of integrated delivery system with a view to gain insight into long-term care and prognosis of the patients, and in hopes of improving future policymaking by the health authority regarding prediction, planning, and management of health care, and providing clinical references for health care institutions.
Objectives
An objective of this study is to conduct a retrospective study and statistical analysis in order to investigate long-term ventilator-dependent patients’ prognosis after NHI launched the 4-phase Integrated Delivery System (IDS) for respiratory failure patients in 1998 and launched the Preliminary Integrated Delivery System (IDS) for ventilator-dependent patients in 2000. The ventilator weaning rate, time required for weaning, mortality, survival curve, ICU readmission rate, reasons for readmission to ICU, and home care referral rate are the analytic factors. Another objective of this study is to further investigate common complications in ventilator-dependent patients, such as nosocomial infection density, common sites of infection, bacterial strains, and prevalence rate of pressure sores of the third degree or higher. Hopefully, possible indices for future assessment of the respiratory care provided for long-term ventilator-dependent patients can be created, and clinical references can be provided for health care institutions in enhancing care quality.
Methods and Materials
This study was retrospective longitudinal study, and the subjects consisted of all the patients admitted to respiratory care wards (RCW) of seven regional hospitals in central Taiwan under the Integrated Delivery System (IDS) over the past two years ( 2005-2006 ). Research is conducted on medical records kept by the hospitals, including monthly statistics, nosocomial infection monitoring records, laboratory data, etc. Variables for assessment are, namely ventilator weaning rate, prevalence rate of pressure sores of the third degree or higher, nosocomial infection density, distribution of bacterial strains, ICU readmission rate, and home care referral rate. Also, this study performs statistical analysis of the patients’ ventilator weaning curve and survival curve by the Kaplan-Meier method using SPSS 10.0 statistical software, providing the ventilator weaning rates and mortality of the long-term ventilator-dependent patients. The post-admission survival correlation between the total number of diseases, multiple risk factors is studied by Cox regression analysis.
Result
This study shows that the subjects totaled 625, admissions totaled 771, aged 72.4±13.8 on average, 62.1% male (n=388), and 37.9% female (n=237). As regards the outcome of care delivery in respiratory care wards (RCW), among the 625 patients, 47 (7.5%) were successfully weaned from ventilator after a mean time of mechanical ventilation of 174±194 days, 205 either died in hospital or were discharged from hospital for being dying, and, with a mortality rate of 32.8%, the patients had lived for 323±417 days on average before their decease. Among the 771 admissions, 234 (30.35%) were discharged from hospital for continued treatment, including 182 (23.61%) readmissions to ICU, 44 (5.71%) referrals to other respiratory care wards and general wards, five readmissions to ER immediately followed by readmission to hospital, one (0.13%) referral to a nursing home, and two (0.26%) referrals to respiratory home care.
Among the 47 patients who were weaned from ventilator successfully, 24 (51%) were weaned from ventilator within three months after admission to RCW, and 31 (65%) were weaned from ventilator within six months after admission to RCW. According to admission sources, the patients were classified into two groups, namely “patients from ICU” and “patients not from ICU”. There were no statistically significant difference on the ventilator weaning curves between the two groups’ (Log Rank: 1.75, df:1, P=0.1854).
As regards complications arising from hospitalization, the prevalence rate of third-degree pressure sores was 12.97%, and treatment for the pressure sores took 1.82 months per person-time on average. Nosocomial infection density was 4.82?? in 2005 and 7.79?? in 2006. As for the sites of nosocomial infection in the respiratory care wards (RCW) of the regional hospitals during the two straight years of 2005 and 2006, the urinary tract infection were the mostly common, followed by the respiratory tract, skin and soft tissue. The three frequent bacterial strains were G(-) Escherichia coli, G(-) Proteus mirabilis, and G(-)Pseudomonas aeruginosa.
The patients survival in respiratory care wards (RCW) were, namely a 6-month survival rate of 84%, a 1-year survival rate of 77%, a 2-year survival rate of 63%, a 3-year survival rate of 58%, and a 5-year survival rate of 45%; the median survival time was 4.1 years. According to admission sources, the patients were classified into two groups, namely “patients from ICU” and “patients not from ICU”, Kaplan-Meier survival analysis of the two groups did not reveal any statistically significant difference (Log Rank: 1.09, df:1, P=0.2985). When the patients were classified according to the primary diagnosis given to the ventilator-dependent patients by ICU into six groups accordingly, namely acute lung diseases, chronic obstructive pulmonary diseases (COPD), neuromuscular diseases, after major surgery, cardiovascular diseases, and infectious diseases, survival analysis of these six groups in RCW did not reveal any statistically significant difference (Log Rank: 10.79, df:5, P=0.0558). However, 1-year survival rate turned out to be the highest in the COPD group (91%) and the lowest in the cardiovascular disease group (42%), whereas 2-year survival rate turned out to be the highest in the “infectious diseases” group (75%) and the lowest in the cardiovascular disease group (31%).
Cox regression analysis also did not reveal any statistically significant correlation between the total number of diseases the patient had at admission to
RCW and the patients’ post-admission survival. However, in multi-variants Cox regression analysis for the multiple risk factors, the findings were shown as followed: first, given the same conditions, there was a statistically significant correlation (P<0.01) between age and post-admission survival, as the patients’ mortality hazard ratio during hospitalization increased by 1.020 times when the patients’ age increased by one year; second, given the same conditions, there was a statistically significant correlation (P<0.05) between the renal disease and post-admission survival, as mortality hazard ratio of patients of the same sex and the same age and suffering from the renal disease at the time when the patients were admitted to hospital was 1.719 time that of those free of the renal disease at the time when admitted to hospital ; third, given the same conditions, there was a statistically significant correlation (P<0.05) between the COPD disease and post-admission survival, as mortality hazard ratio of patients of the same sex and the same age and suffering from the COPD disease at the time when the patients were admitted to hospital was 0.725 time that of those free of the renal disease at the time when admitted to hospital.
Conclusion
Working with the Integrated Delivery System (IDS) for ventilator-dependent patients, Taiwanese respiratory care wards (RCW) differ from their American counterparts in terms of case features and health insurance policy, and thus any attempt to compare the two in respect of care delivery is inappropriate. Given a 12.97% prevalence rate of third-degree pressure sores and 1.82 months treatment for the pressure sores per person-time on average, procedures for prevention of pressure sores should be adopted by respiratory care wards. This study discovers a 3.76% incidence rate of institution-based pressure sores. Calculating the prevalence rate of institution-based pressure sores from the number of patients currently having pressure sores is merely useful for describing the extend to which pressure sores affect the respiratory care wards but is not useful for describing the care quality of a respiratory care institution. In the respiratory care wards (RCW), the urinary tract infection is the mostly common nosocomial infection over the past two straight years, and thus the primary goal for long-term ventilator-dependent patients is to prevent urinary tract infections. Where the patients are classified according to the primary diagnosis given to the ventilator-dependent patients by ICU, and then the patients are divided into six groups, survival analysis of the six groups in RCW does not reveal any statistically significant difference (Log Rank: 10.79, df:5, P=0.0558). However, 1-year survival rate turned out to be the highest in the COPD group , and the lowest in the cardiovascular disease group. Cox regression analysis between multiple risk factors and post-admission survival reveals a statistically significant correlation on the patent’ age and whether the patient suffered from the renal and COPD diseases when the patients were admitted to RCW (P=0.002, P= 0.013, P= 0.042).
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