农村与城市环境中的家庭医疗保健质量不同

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‍‍Rural home healthcare agencies perform better on process measures, urban agencies on outcome measures

The quality of home healthcare varies by location, with rural home healthcare agencies initiating care more quickly while urban agencies excel in preventing hospitalizations, according to a new study by researchers at NYU Rory Meyers College of Nursing. The findings are published in the Journal of Rural Health.

Home healthcare—in which healthcare providers, primarily nurses, visit patients’ homes to deliver care—is one of the fastest growing healthcare sectors in the United States. In 2018, more than 5 million Medicare beneficiaries received home healthcare; 9 percent of patients lived in rural areas.

As the use of home healthcare increases across the country, researchers are working to better understand how quality varies and whether there are disparities in care based on location. To understand differences between quality in urban and rural home healthcare, the researchers analyzed national data on home health quality performance measures from the Centers for Medicare and Medicaid Services over five years (2014 to 2018). Their data included 7,908 home health agencies, of which nearly 20 percent (1,537) were in rural areas. Quality performance measures included timely initiation of care (a measure of care process), and hospitalization and emergency department visits (two measures of care outcomes).

The researchers measured numerous differences between urban and rural agencies, both at individual time points and over time, with rural agencies performing better on the care process measure and urban agencies performing better on the outcome measures. Rural agencies consistently initiated care in a timely fashion, meaning that they quickly started home care upon a doctor’s orders or within two days of hospital discharge or referral to home care.  

“Providing early, intensive visits to patients during a home health episode has been shown to be effective in reducing hospitalization and improving functional status, so timely initiation of care is a critical component of quality home care for patients,” said Chenjuan Ma, PhD, MSN, an assistant professor at NYU Meyers and the study’s lead author. “Strong relationships between rural home health agencies and local hospitals, as evidenced in previous research, may be facilitating the timely initiation of home healthcare to rural patients.”

In contrast, urban agencies consistently performed better on preventing hospitalization and emergency room visits during home care over time—although, notably, emergency department visits increased over the five years studied for both urban and rural home health agencies. These gaps between rural and urban agencies were steady over time except the gap in hospitalization, which narrowed slightly over time.  

“Our study highlights the persistence of disparities in quality of home healthcare. Limited improvements have been made in the quality of home healthcare over time, and the gaps in quality of care did not significantly shrink between rural and urban agencies,” added Ma.

The researchers stress the importance of reducing rural-urban disparities by taking into account the unique geographic, staffing, and health challenges facing agencies. For instance, in addition to staffing and resource challenges, providers from rural home health agencies often spend a significant amount of time traveling to and from patient homes, which could result in less efficient care delivery and could ultimately influence outcomes. In addition, reports on rural and urban recipients of home healthcare suggest that rural patients are in poorer overall health status than their urban counterparts.

Additional study authors include Andrea Devoti of the National Association for Home Care & Hospice and Melissa O’Connor of the Villanova University M. Louise Fitzpatrick College of Nursing.

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根据纽约大学罗里迈耶斯护理学院研究人员的一项新研究，家庭医疗保健的质量因地点而异，农村家庭医疗保健机构启动护理的速度更快，而城市机构在预防住院方面表现出色。研究结果 发表在 《农村卫生杂志》上。

家庭医疗保健——医疗保健提供者，主要是护士，到患者家中提供护理——是美国发展最快的医疗保健行业之一。2018 年，超过 500 万医疗保险受益人接受了家庭医疗保健；9% 的患者生活在农村地区。

随着全国范围内家庭医疗保健使用的增加，研究人员正在努力更好地了解质量如何变化以及是否存在基于位置的护理差异。为了了解城市和农村家庭医疗保健质量之间的差异，研究人员分析了来自医疗保险和医疗补助服务中心五年（2014 年至 2018 年）的家庭健康质量绩效指标的全国数据。他们的数据包括 7,908 个家庭卫生机构，其中近 20%（1,537 个）位于农村地区。质量绩效衡量指标包括及时启动护理（衡量护理过程）以及住院和急诊就诊（衡量护理结果的两种衡量标准）。

研究人员测量了城市和农村机构之间的许多差异，无论是在个别时间点还是随着时间的推移，农村机构在护理过程测量方面表现更好，而城市机构在结果测量方面表现更好。农村机构始终如一地及时启动护理，这意味着他们根据医生的命令或在出院或转诊到家庭护理的两天内迅速开始家庭护理。 

“在家庭健康事件期间对患者提供早期、密集的访问已被证明可有效减少住院和改善功能状态，因此及时开始护理是为患者提供优质家庭护理的关键组成部分，”  Chenjuan Ma 博士说， MSN是纽约大学迈耶斯分校的助理教授，也是该研究的主要作者。“正如先前的研究所证明的那样，农村家庭保健机构与当地医院之间的牢固关系可能有助于及时向农村患者启动家庭保健。”

相比之下，随着时间的推移，城市机构在预防家庭护理期间住院和急诊就诊方面始终表现更好——尽管值得注意的是，在研究的五年中，城市和农村家庭卫生机构的急诊就诊次数都有所增加。这些农村和城市机构之间的差距随着时间的推移是稳定的，除了住院方面的差距，随着时间的推移略有缩小。 

“我们的研究强调了家庭医疗保健质量差异的持续存在。随着时间的推移，家庭医疗保健质量的改善有限，农村和城市机构之间的护理质量差距并没有显着缩小，”马补充道。

研究人员强调了通过考虑机构面临的独特地理、人员配备和健康挑战来缩小城乡差距的重要性。例如，除了人员配备和资源方面的挑战外，农村家庭卫生机构的提供者通常会花费大量时间往返于患者家中，这可能会导致护理效率降低并最终影响结果。此外，关于农村和城市家庭医疗保健接受者的报告表明，农村患者的整体健康状况比城市患者差。

其他研究作者包括美国家庭护理与临终关怀协会的 Andrea Devoti 和维拉诺瓦大学 M. Louise Fitzpatrick 护理学院的 Melissa O'Connor。

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