Lê C T, Winter T D, Boyd K J, Ackerson L, Hurley L B
Department of Family Medicine Services, Kaiser Permanente Medical Center, Santa Rosa, CA 94503, USA.
Am J Manag Care. 1998 May;4(5):647-57.
To evaluate the function and effectiveness of a multidisciplinary team for managing human immunodeficiency virus (HIV) infection, we conducted a follow-up cohort study of HIV-positive patients managed according to a clinical care path at a staff-based health maintenance organization (HMO). The study group consisted of 230 HIV-positive health plan members who received care at the Kaiser Permanente Santa Rosa medical center (KPMC-SRO). In 1994, the comparison group consisted of 4747 HIV-positive health plan members who received care at Kaiser Permanente's 18 other medical centers in northern California. The percentages of acquired immunodeficiency syndrome (AIDS) and HIV-positive patients as determined by CD4+ T-cell counts were similar (P = 0.97). Compared with patients at the other Kaiser Permanente medical centers, KPMC-SRO patients had more visits with nurse practitioners (rate ratio [RR] = 1.72) and nutritionists (RR = 12.3) and fewer visits with primary care physicians (RR = 0.82). More HIV-positive members at KPMC-SRO received social workers' services (27% at KPMC-SRO vs 6% for patients at the other Kaiser Permanente medical centers) and fewer used emergency services (RR = 0.92) and psychiatric services (RR = .89). At KPMC-SRO, the mean number of days that AIDS patients spent in the hospital decreased from 7.8 (1991) to 2.01 (1994). Hospital admissions were fewer (AIDS patients, RR = 0.67; HIV-positive patients without AIDS, RR = 0.45), and length of stay was briefer, compared with patients at the other Kaiser Permanente Medical Centers. The mean cost of HIV-related drugs for patients seen at KPMC-SRO ($2343 per infected member) was lower than that for patients seen elsewhere in the region ($3289 per infected member). These results suggest that in an HMO setting, managed care provided by a dedicated interdisciplinary team according to a clinical care path can substantially and favorably affect resource use.
为评估多学科团队管理人类免疫缺陷病毒（HIV）感染的功能和效果，我们在一家以员工为基础的健康维护组织（HMO）中，对按照临床护理路径管理的HIV阳性患者进行了一项随访队列研究。研究组由230名在凯撒永久医疗集团圣罗莎医疗中心（KPMC-SRO）接受治疗的HIV阳性健康计划成员组成。1994年，对照组由4747名在凯撒永久医疗集团位于北加利福尼亚的其他18家医疗中心接受治疗的HIV阳性健康计划成员组成。通过CD4+T细胞计数确定的获得性免疫缺陷综合征（AIDS）患者和HIV阳性患者的百分比相似（P = 0.97）。与凯撒永久医疗集团其他医疗中心的患者相比，KPMC-SRO的患者接受执业护士诊疗（率比[RR]=1.72）和营养师诊疗（RR = 12.3）的次数更多，而接受初级保健医生诊疗的次数更少（RR = 0.82）。KPMC-SRO有更多的HIV阳性成员接受了社会工作者的服务（KPMC-SRO为27%，而凯撒永久医疗集团其他医疗中心的患者为6%），使用急诊服务（RR = 0.92）和精神科服务（RR = 0.89）的人数更少。在KPMC-SRO，艾滋病患者的平均住院天数从1991年的7.8天降至1994年的2.01天。与凯撒永久医疗集团其他医疗中心的患者相比，住院人数更少（艾滋病患者，RR = 0.67；无艾滋病的HIV阳性患者，RR = 0.45），住院时间更短。在KPMC-SRO接受诊疗的患者，其与HIV相关药物的平均费用（每位感染成员2343美元）低于该地区其他地方的患者（每位感染成员3289美元）。这些结果表明，在HMO环境中，由专门的跨学科团队按照临床护理路径提供的管理式护理可以对资源利用产生重大且有利的影响。
