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5-Year Readmission Status and Risk Factors for Senile Dementia Patients: A Study Based on Chengdu Municipal Medical Insurance Database
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摘要:目的 研究成都市老年痴呆住院患者再入院现状，分析再入院的第一诊断、经济负担和影响因素。方法 本次研究对象为参加了成都市城镇职工基本医疗保险（简称“城职医保”）和城乡居民基本医疗保险（简称“城居医保”），且在2013–2017年间有痴呆诊断的60岁及以上的住院患者。采用秩和检验及卡方检验分析再入院率及住院经济负担在不同特征对象中的差异，并应用logistic回归分析影响再入院的因素。结果 5年间老年痴呆住院患者共计27881人（78820人次），30 d内再入院率为25.14%（7011/27881），5年内再入院率为45.79%（12767/27881）。12767名再入院患者的再入院第一诊断主要包括痴呆（28.58%）、循环系统（24.26%）和呼吸系统疾病（23.71%）。再入院患者的住院经济负担高于非再入院的患者（Z=33.777，P<0.001）。再入院的发生与高龄〔以60~64岁组为参照，70~74岁组的比值比（odds ratio, OR）=1.123，95%置信区间（confidence interval, CI）：1.019~1.237；75~79岁组的OR=1.108，95%CI：1.007~1.218〕、参加城职医保（OR=1.674，95%CI：1.578~1.775）、痴呆类型（以未特指的痴呆为参照，阿尔茨海默病性痴呆组：OR=1.256，95%CI：1.163~1.357；帕金森氏病性痴呆组：OR=1.774，95%CI：1.658~1.898；混合多种痴呆组：OR=1.750，95%CI：1.457~2.103）、患病情况（以只患有痴呆为参照，患有其他疾病组：OR=0.536，95%CI ：0.493~0.583）、住院天数长（OR=1.593，95%CI：1.552~1.635）和医院等级低（以三级医院为参照，二级医院的OR=1.319，95%CI：1.248~1.395；一级医院的OR=1.744，95%CI：1.608~1.891；其他医院的OR=1.465，95%CI：1.311~1.637）有关。结论 老年痴呆患者30 d内再入院率高，再入院患者住院经济负担大。参加医保的人群中，高龄、参加城职医保、阿尔茨海默病性痴呆、帕金森氏病性痴呆、混合多种痴呆、未合并其他疾病的痴呆、住院天数长、住院医院等级低与再入院的发生相关，具体机制尚需进一步研究，以期减少老年痴呆患者再入院的发生，从而减轻疾病经济负担。Abstract:Objective To study the status quo of the readmission of senile dementia patients in Chengdu, and to analyze the primary diagnosis, the economic burden and the influencing factors of readmission.Methods Dementia inpatients aged 60 and above in Chengdu were the subjects of this study. The subjects were diagnosed with dementia between 2013 and 2017. Their heath insurance coverage was either the basic medical insurance for urban employees in Chengdu or the basic medical insurance for urban and rural residents of Chengdu. The rank sum test and the chi-square test were conducted to analyze the differences in readmission rate and the economic burden of hospitalization among subjects with different characteristics. Logistic regression was done to analyze the factors affecting readmission.Results The total number of dementia inpatients over the 5-year period was 27881 patients (78820 admissions). The 30-day readmission rate was 25.14% (7011/27881) and the 5-year readmission rate was 45.79% (12767/27881). The primary diagnoses of 12767 readmitted patients mainly included dementia (28.57%), circulatory system diseases (24.26%), and respiratory system diseases (23.71%). The economic burden of hospitalization was higher for readmitted patients than that of patients who were not readmitted (Z=33.777, P<0.001). The occurrence of readmission was correlated to the following factors, advanced age (compared to that of the 60-65 yr. group, the 70-75 yr. group: odds ratio [OR]=1.123, 95% confidence interval [CI]: 1.019-1.237, and the 75-80 yr. group: OR=1.123, 95% CI: 1.108-1.218), participation in the basic medical insurance for urban employees (OR=1.674, 95% CI: 1.578-1.775), types of dementia (compared to unspecified dementia, Alzheimer's dementia group: OR=1.256, 95% CI: 1.163-1.357, Parkinson's disease dementia group: OR=1.774, 95% CI: 1.658-1.898, and mixed-type dementia group: OR=1.750, 95% CI: 1.457-2.103), disease condition (compared with patients with only dementia, those who have other diseases: OR=0.536, 95% CI : 0.493-0.583), length of hospital stay (OR=1.593, 95% CI: 1.552-1.635), and staying at a lower level hospital (compared to that of tertiary hospitals, secondary hospitals: OR=1.319, 95% CI: 1.248-1.395, primary hospitals: OR=1.744, 95% CI: 1.608-1.891, and other hospitals: OR=1.465, 95% CI: 1.311-1.537).Conclusion Senile dementia patients have a high 30-day readmission rate, and the readmission entails heavy economic burdens on the patients. For the populations covered by medical insurance, the following features are correlated to the occurrence of readmission: advanced age, coverage by the basic medical insurance for urban employees, Alzheimer's dementia, Parkinson's disease dementia, mixed-type dementia, dementia patients without other comorbidities, extended length of stay, and hospitalization at a lower level hospital. However, further research is needed for better understanding of the specific mechanisms so that readmission of senile dementia patients can be reduced and the economic burden of the disease can be minimized.
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Keywords:
- Senile dementia /
- Readmission /
- Risk factors
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痴呆症（dementia）是一种主要体现为记忆、思考、行为和日常活动能力衰退的综合征，最常见的类型是阿尔茨海默病性痴呆（约60%~70%），其次是血管性痴呆、路易体痴呆和额颞叶痴呆[1]。65岁及以上痴呆症患者占痴呆症病例的90%至98%。老年痴呆严重影响了老人的认知功能、日常生活能力和生存质量[2]。《2015年全球阿尔茨海默病报告》显示，全球有4600多万人患有老年痴呆，到2050年，这个数字估计将增加到1.32亿[3]。我国60岁及以上老年人痴呆患病率约为5.14%～5.60%[4-6]。
由于痴呆的病程长，且患者有一半的时间生活不能自理，加之伴发的痴呆精神行为症状，其疾病负担较其他疾病更为沉重[7-8]。2015年，一项全国性的大规模调查显示，我国老年痴呆患者人均医疗和照护费用每年为12.4万元，所造成的疾病经济负担为1.1万亿元，约为我国当年GDP的1.47%，高于其他国家的平均水平（1.09%）[9]。研究显示，老年痴呆患者是再次入院的高危人群，30 d内再住院率为11.8%～23.6%[10-12]。国外研究发现，痴呆患者的高再入院率与以下几类因素有关，包括：①人口学特征，如高龄[12-13]、女性[14-15]；②伴发疾病，如伴发心血管疾病（如心力衰竭）[16-17]、肺炎[17]、跌倒和虚弱[18]；③医疗保健利用，如入院期间住院时间较长[10, 14]、转到其他医院[14]、出院计划不充分[19]；④人际关系，如独居[14]、照顾者较高的护理压力[14]及较少的照顾者支持[19]等。国内研究集中于评估个性化护理和跨学科团队协作护理降低痴呆患者的再入院[20-22]，但关于老年痴呆患者再入院率以及再入院原因和影响因素的研究相对缺乏。因此，本研究探究了老年痴呆患者再入院的情况，并评估其再入院率、再入院经济负担，分析再入院的原因以及影响因素，为老年痴呆的科学防治及减轻医疗负担提供一定依据。
1. 资料与方法
1.1 资料来源
本研究利用成都市医疗保险数据库，抽取了2013–2017年的成都市有医保赔付记录的老年痴呆住院患者的出院信息，具体信息包括：医保编号、医保类型、性别、年龄、出院诊断、出入院时间、患者住院的医院名称和等级以及住院费用等。
1.2 研究对象
本次研究对象为参加了成都市城镇职工基本医疗保险（简称“城职医保”）和城乡居民基本医疗保险（简称“城居医保”），且在2013–2017年间有痴呆诊断的60岁及以上的住院患者。研究经四川大学华西第四医院/华西公共卫生学院伦理委员会审批（审批号：Gwll2022010）。
纳入标准：①年龄≥60岁且医保赔付时间为2013年1月1日–2017年12月31日；②患者前八个出院诊断中任意一个诊断符合国际疾病与分类诊断标准第10版（ICD-10）中的痴呆诊断标准，具体包括：F00（阿尔茨海默病性痴呆）/F01（血管性痴呆）/F02（分类于他处的其他疾病引起的痴呆）/F03（未特指的痴呆）/G20（帕金森氏病性痴呆）/G30（阿尔茨海默病）。排除标准：①排除2013–2017年间由城居医保转变为城职医保或由城职医保转变为城居医保额患者；②排除2013年1月1日前入院的患者。最终分析的老年痴呆患者共计27 881人，78 820条住院记录，每次住院将被作为一个独立事件进行分析。见图1。
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图 1 研究对象筛选流程图Figure 1. Flowchart of the screening process of the subjects of the studyThe codes “F00”, “F01”, “F02”, “F03”, “G20”, and “G30” are the diagnostic codes for dementia in the International Classification of Diseases. F00: Alzheimer's dementia; F01:Vascular dementia; F02: Dementia caused by other diseases classified elsewhere; F03: Unspecified dementia; G20: Parkinson's diseasedementia; G30: Alzheimer's disease.1.3 统计学方法
计量资料用
$ \bar x \pm s $ 、四分位数M（Q1～Q3）表示，计数资料用频数和百分比表示。单因素分析使用卡方检验和秩和检验，多因素分析采用logistic回归模型，检验水准α=0.05。采用统计软件STATA 15.0对数据进行分析。本研究关于成都市老年痴呆住院患者的再入院率（R）计算公式为[23]：
$${\rm{R}}=\dfrac{\mathrm{某一时间段内老年痴呆再入院人数}}{2013–2017\mathrm{年总的老年痴呆住院人数}}\times 100\mathrm{\%}。 $$ 2. 结果
2.1 一般情况
见表1。按住院人次统计，78820条老年痴呆住院记录中，女性住院人次数占比（56.77%）略高；60～65岁有5969（7.57%）人次，80岁以上有33607（42.64%）人次；城职医保住院人次数约为城居医保的4倍；36.66%人次的住院是因为帕金森氏病性痴呆，26.74%人次为阿尔茨海默病性痴呆；73.07%人次的患者住院时间不超过一个月；47.45%人次的住院发生在二级医院，其次是三级医院（33.80%）；12767名再住院患者产生的住院次数共计63706次，平均每人住院4.99次。
表 1 老年痴呆住院患者基本情况Table 1. Basic information of the hospitalized senile dementia patientsVariable Number of hospitalized cases with dementia Number of hospitalized patients with dementia Total (n=78820) Readmission cases
(n=63706)Total
(n=27881)Readmission patients
(n=12767)Non-readmission
patients (n=15114)χ2 P* Gender/case (%) 0.709 0.400 Male 34075 (43.23) 27013 (42.40) 12962 (46.49) 5900 (46.21) 7062 (46.72) Female 44745 (56.77) 36693 (57.60) 14919 (53.51) 6867 (53.79) 8052 (53.28) Age/case (%) 14.155 0.007 60 yr.- 5969 (7.57) 4399 (6.91) 2846 (10.21) 1276 (9.99) 1570 (10.39) 65 yr.- 8131 (10.32) 6201 (9.73) 3481 (12.49) 1551 (12.15) 1930 (12.77) 70 yr.- 13206 (16.75) 10532 (16.53) 5078 (18.21) 2404 (18.83) 2674 (17.69) 75 yr.- 17907 (22.72) 14593 (22.91) 6248 (22.41) 2934 (22.98) 3314 (21.93) 80 yr.- 33607 (42.64) 27981 (43.92) 10228 (36.68) 4602 (36.05) 5626 (37.22) Basic medical insurance/case (%) 555.540 <0.001 Urban and rural residents 15996 (20.29) 10868 (17.06) 7833 (28.09) 2705 (21.19) 5128 (33.93) Urban employees 62824 (79.71) 52838 (82.94) 20048 (71.91) 10062 (78.81) 9986 (66.07) Type of dementia/case (%) 399.470 <0.001 Alzheimer's dementia 21076 (26.74) 18325 (28.76) 5805 (20.82) 3054 (23.92) 2751 (18.20) Vascular dementia 10334 (13.11) 8346 (13.10) 3247 (11.65) 1259 (9.86) 1988 (13.15) Parkinson's disease dementia 28897 (36.66) 23061 (36.20) 11403 (40.90) 5576 (43.61) 5827 (38.62) Unspecified dementia 15576 (19.76) 11298 (17.74) 6885 (24.69) 2607 (20.42) 4278 (28.30) Mixed dementia 2937 (3.73) 2676 (4.20) 541 (1.94) 280 (2.19) 261 (1.73) Disease condition/case (%) 608.540 <0.001 Only having dementia 9921 (12.59) 8801 (13.82) 3288 (11.79) 2168 (16.98) 1120 (7.41) Having other diseases 68899 (87.41) 54905 (86.18) 24593 (88.21) 10599 (83.02) 13994 (92.59) Length of stay/case (%) 1818.200 <0.001 0 d- 13050 (16.56) 8181 (12.84) 7333 (26.30) 2464 (19.30) 4869 (32.22) 7 d- 23214 (29.45) 17055 (26.77) 10639 (38.16) 4480 (35.09) 6159 (40.75) 14 d- 21326 (27.06) 18154 (28.50) 6425 (23.04) 3253 (25.48) 3172 (20.98) 30 d- 13637 (17.30) 12856 (20.18) 2301 (8.25) 1520 (11.91) 781 (5.17) 90 d- 7593 (9.63) 7460 (11.71) 1183 (4.25) 1050 (8.22) 133 (0.88) Hospital level/case (%) 147.550 <0.001 Tertiary 26638 (33.80) 19505 (30.62) 12466 (44.72) 5333 (41.77) 7133 (47.19) Secondary 37401 (47.45) 32044 (50.30) 10442 (37.45) 5085 (39.83) 5357 (35.44) Primary 11350 (14.40) 9748 (15.30) 3285 (11.78) 1683 (13.18) 1602 (10.60) Others 3431 (4.35) 2409 (3.78) 1688 (6.05) 666 (5.22) 1022 (6.77) * Readmission patients vs. non-readmission patients. 按住院人数统计，5年间老年痴呆住院患者共计27881人。以其第一条住院记录为基线，女性14919（53.51%）人；年龄以80岁以上居多，占36.68%（10228/27881）；城职医保痴呆住院人数占比大，为71.91%（20048/27881）；40.90%（11403/27881）的老年痴呆住院患者的痴呆类型是帕金森氏病性痴呆；超过80%的老年痴呆住院患者诊断中除了有痴呆诊断以外，还有其他疾病。再入院患者12767人，非再入院患者15114人。比较老年痴呆患者不同特征下再入院构成比的差异，结果显示，再入院患者和非再入院患者在基线时的年龄、医保类型、痴呆类型、患病情况、住院天数和住院医院等级的差异有统计学意义（P<0.05）。见表1。
将2013–2017年间再入院的老年痴呆患者的第一次入院作为首次入院，其余的均为再入院患者的再次入院记录，共计50939条记录。再次入院记录的第一诊断中，排名第一位的是痴呆，占28.58%（14556/50939）；其次是循环系统疾病，占24.26%（12358/50939）；排名第三的是呼吸系统疾病，占23.71%（12078/50939）。消除通货膨胀的影响后，78820人次老年痴呆住院患者的次均住院费用中位数为8343.01元（4982.20元，14373.57元）。
2.2 住院频次
27881名老年痴呆住院患者中，住院频次最少为1次，最多的有66条住院记录。54.21%（15114/27881）的患者只住院一次，其住院频次只占老年痴呆总住院频次的19.18%（15114/78820），重复住院的患者住院频次占80.82%，是一次住院患者的4倍。4.06%（1132/27881）的老年痴呆患者有过10次以上的住院经历，其产生的住院频次占总住院频次的26.07%（20549/78820）。见表2。
表 2 5年内住院频次分布情况Table 2. Frequency distribution of hospitalizationswithin 5 yearsFrequency of hospitalization Number of patients/case (%)
, n=27881Number of cases/case (%), n=78820 1 15114 (54.21) 15114 (19.18) 2−5 9455 (33.91) 26606 (33.75) 6−10 2180 (7.82) 16551 (21.00) >10 1132 (4.06) 20549 (26.07) 2.3 成都市老年痴呆患者的再入院率
见图2、表3。2013–2017年老年痴呆住院患者30 d内的再入院率最高，为25.14%（7011/27881）；5年内再入院率为45.79%（12767/27881）。不同性别、不同医保类型的老年痴呆患者30 d内的再入院率的差异均有统计学意义（P<0.05），女性的30 d内再入院率高于男性，城职医保的老年痴呆患者再入院率高于城居医保患者。
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图 2 老年痴呆患者再入院率（n=27881）Figure 2. Rate of readmissions occurring within the corresponding time period (n=27881)Readmission time interval= The lapse of time between the last discharge and the subsequent readmission. If a patient had more than two hospitalization records, the shortest time interval was counted as the the readmission time interval. For example, if a patient had 3 admission records, and the time interval between the first and second admissions was 15 days, while the time interval between the second and third admissions was 40 days, the readmission interval for this particular patient was then counted as less than 30 days.表 3 老年痴呆患者不同时间段内再入院率的差异（n=27881）Table 3. Differences in readmission rate among senile dementia patients readmitted at different time intervals (n=27881)Readmission time
interval/dGender/case (%) Basic medical insurance/case (%) Male
(n=12962)Female
(n=14919)χ2 P Urban and rural residents
(n=7833)Urban employees
(n=20048)χ2 P ≤30 3157 (24.36) 3854 (25.83) 4.764 0.029 1251 (15.97) 5760 (28.73) 305.180 <0.001 31–90 3968 (30.61) 4713 (31.59) 1.595 0.207 1663 (21.23) 7018 (35.01) 274.570 <0.001 91–180 4560 (35.18) 5325 (35.69) 0.366 0.545 1958 (25.00) 7927 (39.54) 260.510 <0.001 181–365 5180 (39.96) 6044 (40.51) 0.357 0.550 2286 (29.18) 8938 (44.58) 248.720 <0.001 >365 5900 (45.52) 6867 (46.03) 0.260 0.610 2705 (34.53) 10062 (50.19) 217.180 <0.001 The same notes as those of Fig 2. 2.4 再入院患者住院经济负担
见表4。非再入院患者住院费用中位数为6891.52元（3855.26元，11722.42元），而再入院患者的次均住院费用中位数为8767.27元（5352.28元，15047.47元）。将非再入院患者与再入院患者的经济负担进行比较，结果显示，再入院患者平均每次住院医疗费用总额、次均自费金额均高于非再入院的患者（P<0.001）。
表 4 再入院患者的住院经济负担Table 4. Enonomic burden of readmission on the patientsVariable Readmission patients
(n=12767)Non-readmission patients
(n=15114)Z P Average hospitalization cost/¥, median (Q1, Q3) 8767.27 (5352.28, 15047.47) 6 891.52 (3855.26, 11722.42) 33.777 <0.001 Average hospitalization out-of-pocket payment/¥, median (Q1, Q3) 510.01 (184.69, 1502.95) 441.95 (181.66, 989.06) 13.563 <0.001 2.5 再入院影响因素
见表5。以是否发生再入院为因变量进行logistic回归分析，将单因素有影响的基线时的变量（医保类型：城居医保=0，城职医保=1；痴呆类型：未特指的痴呆=1，阿尔茨海默病性痴呆=2，血管性痴呆=3，帕金森氏病性痴呆=4，混合多种痴呆=5；患病情况：仅有痴呆诊断=0，除痴呆诊断外还有其他疾病=1；医院等级：三级医院=1，二级医院=2，一级医院=3，其他=4）以及性别（男性=0，女性=1）和年龄（60～64岁=1，65～69岁=2，70～74岁=3，75～79岁=4，80岁及以上=5）基本特征纳入模型，其中年龄、痴呆类型、医院等级作为哑变量形式纳入。结果显示：与60～64岁年龄组相比，年龄在70～79岁之间的患者更容易发生再入院；城职医保的老年痴呆患者发生再入院的风险是城居医保老年痴呆患者的1.674倍〔95%置信区间（confidence interval, CI）：1.578～1.775〕；与未特指的痴呆患者相比，除血管性痴呆以外的痴呆类型，发生再入院的风险均更高，其中阿尔茨海默病性痴呆发生再入院的风险是其的1.256倍（95%CI：1.163～1.357）；患病情况方面，除患有痴呆外还有其他疾病的患者发生再入院的风险较只患有痴呆者低（OR=0.536，95%CI：0.493～0.583）；就住院天数而言，第一次住院的住院天数每增长1 d，老年痴呆患者发生再入院的风险增加59.3%；与三级医院相比，在其他等级医院的老年痴呆患者发生再入院的风险更高，在一级医院住院的患者再入院风险为OR=1.744（95%CI：1.608～1.891）。
表 5 老年痴呆患者发生再入院的多因素logistic回归分析Table 5. Logistic regression analysis of the readmission of senile dementia patientsVariable β SE Wald χ2 P OR (95% CI) Gender (Male) Female 0.048 0.026 1.880 0.061 1.049 (0.998−1.103) Age (60 yr.-) 65 yr.- 0.001 0.053 0.020 0.987 1.001 (0.902−1.111) 70 yr.- 0.116 0.049 2.340 0.019 1.123 (1.019−1.237) 75 yr.- 0.102 0.048 2.110 0.035 1.108 (1.007−1.218) 80 yr.- 0.030 0.047 0.640 0.525 1.030 (0.940−1.130) Basic medical insurance (Urban and rural residents) Urban employees 0.515 0.030 17.140 <0.001 1.674 (1.578−1.775) Type of dementia (Unspecified dementia) Alzheimer's dementia 0.228 0.039 5.780 <0.001 1.256 (1.163−1.357) Vascular dementia −0.154 0.046 −3.320 0.001 0.858 (0.783−0.939) Parkinson's disease dementia 0.573 0.034 16.65 <0.001 1.774 (1.658−1.898) Mixed dementia 0.560 0.094 5.980 <0.001 1.750 (1.457−2.103) Disease condition (Having only dementia) Having other diseases −0.624 0.043 −14.550 <0.001 0.536 (0.493−0.583) Length of stay 0.466 0.013 34.770 <0.001 1.593 (1.552−1.635) Hospital level (Tertiary) Secondary 0.277 0.029 9.710 <0.001 1.319 (1.248−1.395) Primary 0.556 0.041 13.410 <0.001 1.744 (1.608−1.891) Others 0.382 0.057 6.750 <0.001 1.465 (1.311−1.637) Constant −1.130 0.071 −15.930 <0.001 0.323 (0.281−0.371) β: Partial regression coefficient; SE: Standard error; OR: Odd ratio; CI: Confidence interval. 3. 讨论
3.1 再入院率和再入院第一诊断
本研究发现，老年痴呆住院患者中，非再入院患者和再入院患者人数相当，但再入院的人产生的住院记录却是非再入院患者的4倍。尽管只有4.06%的老年痴呆患者有过10次以上的住院经历，但其产生的住院频次却占总住院频次的26.07%，可见少数有过10次以上住院经历的患者产生的住院频次合计多于只有1次住院经历的患者，提示老年痴呆患者容易反复入院，痴呆住院的医疗卫生服务和医疗保险支出大部分都用在了少数的、经常住院的患者中。本研究的结果显示，老年痴呆患者30 d内的再入院率为25.14%，5年内总再入院率为45.79%。有研究报道，德国、美国、澳大利亚的老年痴呆患者30 d再入院率分别为11.8%[11]、18.9%[10]、23.6% [12]，均低于本研究的结果。这可能与各国居民健康状况及卫生服务利用情况存在巨大差异有关[24]。除此之外，本研究发现老年痴呆的30 d再入院率也高于其他疾病：心血管疾病相关的30 d内再入院率男性为11.7%、女性为10.2%[25]，慢性阻塞性肺疾病患者的30 d再入院率为20%。因此，老年痴呆的防治和管理是亟待解决的公共卫生问题。
此外，研究还发现再入院老年痴呆患者的再入院第一诊断主要包括痴呆（28.58%）、循环系统疾病（24.26%）和呼吸系统疾病（23.71%）。既往研究显示，循环系统、呼吸系统、消化系统、心理和行为问题是痴呆患者再住院的主要原因[13, 26]，与本研究的结果相一致[17-18]。随着患病时间的延长，痴呆患者的认知功能损害加重，常伴发神经精神症状导致患者再次入院[27]。另外，有研究已经揭示了各种心血管异常与痴呆之间的联系，如心力衰竭、冠状动脉疾病、心房颤动和血管病变。大量的工作已经指出了这种头部到心脏的联系，主要集中在脑灌注不足和神经元退化之间的联系[28]。在疾病的晚期，痴呆患者还可见锥体束征阳性[29]，即出现运动障碍，患者将长期卧床，增加了患者肺部感染的风险，导致再入院的发生[30-31]。
3.2 再入院患者住院经济负担
本研究以2013年为基期，消除通货膨胀的影响后，计算得到再入院患者次均住院费用为12849.93元，次均自费金额为1602.09元。国内关于老年痴呆患者的住院经济负担研究发现，住院患者月均直接经济负担为9751.5元[32]，每年医疗总费用平均为90946.4元、中位数70800元[33]。与以往的研究不同的是，本研究直接通过医保数据中的住院费用计算直接经济负担，较既往研究通过询问收集老年痴呆患者住院及其他医疗花费更为准确。但是，医保数据只包括住院所花费的直接医疗费用，缺乏门诊或其他机构中的直接花费以及家属因照顾老年痴呆患者导致的误工所产生的间接经济负担。
研究发现再入院患者平均每次住院医疗总费用、平均每次住院自费金额均高于非再入院的患者。这意味着老年痴呆再入院患者住院花费要高于非再入院的患者。一方面，再入院的患者往往病情较为严重和复杂，且随着老年痴呆的进展，患者伴发的其他疾病越来越多[34]，例如高血压、糖尿病、肺部疾病。另一方面，多次住院的患者可能年龄更大，年龄越大的老年痴呆患者，身体机能越差，疾病相对比较严重[34]，因此所需费用越多。除此之外，由于病情原因需要反复入院的患者往往其住院天数更长[35]，毋庸置疑，住院的时间越久，住院花费就越大。总之，老年痴呆患者反复入院造成了极大的经济负担。
3.3 再入院影响因素
通过多因素回归分析发现，老年痴呆患者再入院与基线时的高龄、参加城职医保、痴呆类型、患病情况、住院天数以及低等级医院就诊相关。既往研究显示，年龄越大，再次住院的风险就越大[12-13]，与本研究结果相同。随着年龄的增加，老年痴呆患者病情加重、身体机能下降将导致再入院的发生[36]。而本研究未观察到80岁以上老年人与60～65岁老年患者再入院的差异，可能与年龄大的老年痴呆患者由于其他原因（如死亡）无法再次入院有关[26]。城职医保与患者再入院相关可能是因为城职医保的保障水平更高[37]，且其收入相对城居医保患者高，支付能力较强，有更好的经济实力去利用医疗资源[38]。痴呆类型方面，基线时诊断中只有痴呆的患者可能是初诊为痴呆的患者，他们处在疾病的前期阶段，随着病情的发展，往往会因为伴发其他疾病而入院进行治疗；并且初诊患者的照护者可能缺乏经验，导致痴呆相关症状无法处理，因此再入院的风险可能更高，但我们没有数据进一步说明这个问题，其原因还有待深入的研究。已有研究表明长时间的住院治疗与再次住院有关[10, 14]，长时间住院的患者往往病情较为严重，因此再入院的风险更高，与本研究的结果一致。在等级越低的医院住院，老年痴呆患者再入院风险越高。目前，我国痴呆诊治相关医疗资源主要集中在大型综合医院，其对痴呆患者的管理更有效[39]，因此在三级医院就诊的老年痴呆患者再入院风险更低，而低等级医院缺乏对痴呆患者的管理能力，基层医务工作者缺乏痴呆的诊治经验[40]，加之患者及家属对基层卫生服务能力的不信任[41]，因此在低等级医院就诊的老年痴呆患者发生再入院的可能性更高。此外，对于长期反复住院的患者而言，综合考虑医疗资源以及医疗费用，可能选择三级以外的医院长期住院[42]。
3.4 优势与不足
本研究利用2013–2017年的医保赔付数据对痴呆患者住院和再入院情况进行了描述，并分析了再入院的主要原因、经济负担和影响因素。尽管本研究的样本量较大，但是也存在一定的局限性。首先，本研究缺乏未参与城职和城居医疗保险的老年痴呆患者的信息，也没有门诊利用信息，故不能代表老年痴呆患者对医疗服务的利用的全面情况。其次，由于缺乏详细的临床数据和个体相关变量等信息，因此不能对再入院的原因进行更深入的分析。最后，本研究只用了成都市的医疗保险数据，由于人口、经济和医疗体系的差异，外推性有一定的局限。尽管如此，我们相信这项研究可以激发其他地区的重要研究行动，为老年痴呆的科学防治及减轻医疗负担提供一定依据。
* * *
利益冲突 所有作者均声明不存在利益冲突
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图 1 研究对象筛选流程图
Figure 1. Flowchart of the screening process of the subjects of the study
The codes “F00”, “F01”, “F02”, “F03”, “G20”, and “G30” are the diagnostic codes for dementia in the International Classification of Diseases. F00: Alzheimer's dementia; F01:Vascular dementia; F02: Dementia caused by other diseases classified elsewhere; F03: Unspecified dementia; G20: Parkinson's diseasedementia; G30: Alzheimer's disease.
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图 2 老年痴呆患者再入院率（n=27881）
Figure 2. Rate of readmissions occurring within the corresponding time period (n=27881)
Readmission time interval= The lapse of time between the last discharge and the subsequent readmission. If a patient had more than two hospitalization records, the shortest time interval was counted as the the readmission time interval. For example, if a patient had 3 admission records, and the time interval between the first and second admissions was 15 days, while the time interval between the second and third admissions was 40 days, the readmission interval for this particular patient was then counted as less than 30 days.
表 1 老年痴呆住院患者基本情况
Table 1 Basic information of the hospitalized senile dementia patients
Variable Number of hospitalized cases with dementia Number of hospitalized patients with dementia Total (n=78820) Readmission cases
(n=63706)Total
(n=27881)Readmission patients
(n=12767)Non-readmission
patients (n=15114)χ2 P* Gender/case (%) 0.709 0.400 Male 34075 (43.23) 27013 (42.40) 12962 (46.49) 5900 (46.21) 7062 (46.72) Female 44745 (56.77) 36693 (57.60) 14919 (53.51) 6867 (53.79) 8052 (53.28) Age/case (%) 14.155 0.007 60 yr.- 5969 (7.57) 4399 (6.91) 2846 (10.21) 1276 (9.99) 1570 (10.39) 65 yr.- 8131 (10.32) 6201 (9.73) 3481 (12.49) 1551 (12.15) 1930 (12.77) 70 yr.- 13206 (16.75) 10532 (16.53) 5078 (18.21) 2404 (18.83) 2674 (17.69) 75 yr.- 17907 (22.72) 14593 (22.91) 6248 (22.41) 2934 (22.98) 3314 (21.93) 80 yr.- 33607 (42.64) 27981 (43.92) 10228 (36.68) 4602 (36.05) 5626 (37.22) Basic medical insurance/case (%) 555.540 <0.001 Urban and rural residents 15996 (20.29) 10868 (17.06) 7833 (28.09) 2705 (21.19) 5128 (33.93) Urban employees 62824 (79.71) 52838 (82.94) 20048 (71.91) 10062 (78.81) 9986 (66.07) Type of dementia/case (%) 399.470 <0.001 Alzheimer's dementia 21076 (26.74) 18325 (28.76) 5805 (20.82) 3054 (23.92) 2751 (18.20) Vascular dementia 10334 (13.11) 8346 (13.10) 3247 (11.65) 1259 (9.86) 1988 (13.15) Parkinson's disease dementia 28897 (36.66) 23061 (36.20) 11403 (40.90) 5576 (43.61) 5827 (38.62) Unspecified dementia 15576 (19.76) 11298 (17.74) 6885 (24.69) 2607 (20.42) 4278 (28.30) Mixed dementia 2937 (3.73) 2676 (4.20) 541 (1.94) 280 (2.19) 261 (1.73) Disease condition/case (%) 608.540 <0.001 Only having dementia 9921 (12.59) 8801 (13.82) 3288 (11.79) 2168 (16.98) 1120 (7.41) Having other diseases 68899 (87.41) 54905 (86.18) 24593 (88.21) 10599 (83.02) 13994 (92.59) Length of stay/case (%) 1818.200 <0.001 0 d- 13050 (16.56) 8181 (12.84) 7333 (26.30) 2464 (19.30) 4869 (32.22) 7 d- 23214 (29.45) 17055 (26.77) 10639 (38.16) 4480 (35.09) 6159 (40.75) 14 d- 21326 (27.06) 18154 (28.50) 6425 (23.04) 3253 (25.48) 3172 (20.98) 30 d- 13637 (17.30) 12856 (20.18) 2301 (8.25) 1520 (11.91) 781 (5.17) 90 d- 7593 (9.63) 7460 (11.71) 1183 (4.25) 1050 (8.22) 133 (0.88) Hospital level/case (%) 147.550 <0.001 Tertiary 26638 (33.80) 19505 (30.62) 12466 (44.72) 5333 (41.77) 7133 (47.19) Secondary 37401 (47.45) 32044 (50.30) 10442 (37.45) 5085 (39.83) 5357 (35.44) Primary 11350 (14.40) 9748 (15.30) 3285 (11.78) 1683 (13.18) 1602 (10.60) Others 3431 (4.35) 2409 (3.78) 1688 (6.05) 666 (5.22) 1022 (6.77) * Readmission patients vs. non-readmission patients. 
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表 2 5年内住院频次分布情况
Table 2 Frequency distribution of hospitalizationswithin 5 years
Frequency of hospitalization Number of patients/case (%)
, n=27881Number of cases/case (%), n=78820 1 15114 (54.21) 15114 (19.18) 2−5 9455 (33.91) 26606 (33.75) 6−10 2180 (7.82) 16551 (21.00) >10 1132 (4.06) 20549 (26.07)
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表 3 老年痴呆患者不同时间段内再入院率的差异（n=27881）
Table 3 Differences in readmission rate among senile dementia patients readmitted at different time intervals (n=27881)
Readmission time
interval/dGender/case (%) Basic medical insurance/case (%) Male
(n=12962)Female
(n=14919)χ2 P Urban and rural residents
(n=7833)Urban employees
(n=20048)χ2 P ≤30 3157 (24.36) 3854 (25.83) 4.764 0.029 1251 (15.97) 5760 (28.73) 305.180 <0.001 31–90 3968 (30.61) 4713 (31.59) 1.595 0.207 1663 (21.23) 7018 (35.01) 274.570 <0.001 91–180 4560 (35.18) 5325 (35.69) 0.366 0.545 1958 (25.00) 7927 (39.54) 260.510 <0.001 181–365 5180 (39.96) 6044 (40.51) 0.357 0.550 2286 (29.18) 8938 (44.58) 248.720 <0.001 >365 5900 (45.52) 6867 (46.03) 0.260 0.610 2705 (34.53) 10062 (50.19) 217.180 <0.001 The same notes as those of Fig 2.
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表 4 再入院患者的住院经济负担
Table 4 Enonomic burden of readmission on the patients
Variable Readmission patients
(n=12767)Non-readmission patients
(n=15114)Z P Average hospitalization cost/¥, median (Q1, Q3) 8767.27 (5352.28, 15047.47) 6 891.52 (3855.26, 11722.42) 33.777 <0.001 Average hospitalization out-of-pocket payment/¥, median (Q1, Q3) 510.01 (184.69, 1502.95) 441.95 (181.66, 989.06) 13.563 <0.001
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表 5 老年痴呆患者发生再入院的多因素logistic回归分析
Table 5 Logistic regression analysis of the readmission of senile dementia patients
Variable β SE Wald χ2 P OR (95% CI) Gender (Male) Female 0.048 0.026 1.880 0.061 1.049 (0.998−1.103) Age (60 yr.-) 65 yr.- 0.001 0.053 0.020 0.987 1.001 (0.902−1.111) 70 yr.- 0.116 0.049 2.340 0.019 1.123 (1.019−1.237) 75 yr.- 0.102 0.048 2.110 0.035 1.108 (1.007−1.218) 80 yr.- 0.030 0.047 0.640 0.525 1.030 (0.940−1.130) Basic medical insurance (Urban and rural residents) Urban employees 0.515 0.030 17.140 <0.001 1.674 (1.578−1.775) Type of dementia (Unspecified dementia) Alzheimer's dementia 0.228 0.039 5.780 <0.001 1.256 (1.163−1.357) Vascular dementia −0.154 0.046 −3.320 0.001 0.858 (0.783−0.939) Parkinson's disease dementia 0.573 0.034 16.65 <0.001 1.774 (1.658−1.898) Mixed dementia 0.560 0.094 5.980 <0.001 1.750 (1.457−2.103) Disease condition (Having only dementia) Having other diseases −0.624 0.043 −14.550 <0.001 0.536 (0.493−0.583) Length of stay 0.466 0.013 34.770 <0.001 1.593 (1.552−1.635) Hospital level (Tertiary) Secondary 0.277 0.029 9.710 <0.001 1.319 (1.248−1.395) Primary 0.556 0.041 13.410 <0.001 1.744 (1.608−1.891) Others 0.382 0.057 6.750 <0.001 1.465 (1.311−1.637) Constant −1.130 0.071 −15.930 <0.001 0.323 (0.281−0.371) β: Partial regression coefficient; SE: Standard error; OR: Odd ratio; CI: Confidence interval.
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