Hughes S L, Weaver F M, Giobbie-Hurder A, Manheim L, Henderson W, Kubal J D, Ulasevich A, Cummings J
Cooperative Studies Program Coordinating Center, Edward A. Hines Jr Veterans Affairs Hospital, Hines, Ill, USA.
JAMA. 2000 Dec 13;284(22):2877-85. doi: 10.1001/jama.284.22.2877.
Although home-based health care has grown over the past decade, its effectiveness remains controversial. A prior trial of Veterans Affairs (VA) Team-Managed Home-Based Primary Care (TM/HBPC) found favorable outcomes, but the replicability of the model and generalizability of the findings are unknown.
To assess the impact of TM/HBPC on functional status, health-related quality of life (HR-QoL), satisfaction with care, and cost of care.
Multisite randomized controlled trial conducted from October 1994 to September 1998 in 16 VA medical centers with HBPC programs.
A total of 1966 patients with a mean age of 70 years who had 2 or more activities of daily living impairments or a terminal illness, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD). Intervention Home-based primary care (n=981), including a primary care manager, 24-hour contact for patients, prior approval of hospital readmissions, and HBPC team participation in discharge planning, vs customary VA and private sector care (n=985).
Patient functional status, patient and caregiver HR-QoL and satisfaction, caregiver burden, hospital readmissions, and costs over 12 months.
Functional status as assessed by the Barthel Index did not differ for terminal (P=.40) or nonterminal (those with severe disability or who had CHF or COPD) (P=.17) patients by treatment group. Significant improvements were seen in terminal TM/HBPC patients in HR-QoL scales of emotional role function, social function, bodily pain, mental health, vitality, and general health. Team-Managed HBPC nonterminal patients had significant increases of 5 to 10 points in 5 of 6 satisfaction with care scales. The caregivers of terminal patients in the TM/HBPC group improved significantly in HR-QoL measures except for vitality and general health. Caregivers of nonterminal patients improved significantly in QoL measures and reported reduced caregiver burden (P=.008). Team-Managed HBPC patients with severe disability experienced a 22% relative decrease (0.7 readmissions/patient for TM/HBPC group vs 0.9 readmissions/patient for control group) in hospital readmissions (P=.03) at 6 months that was not sustained at 12 months. Total mean per person costs were 6.8% higher in the TM/HBPC group at 6 months ($19190 vs $17971) and 12.1% higher at 12 months ($31401 vs $28008).
The TM/HBPC intervention improved most HR-QoL measures among terminally ill patients and satisfaction among non-terminally ill patients. It improved caregiver HR-QoL, satisfaction with care, and caregiver burden and reduced hospital readmissions at 6 months, but it did not substitute for other forms of care. The higher costs of TM/HBPC should be weighed against these benefits.
尽管家庭医疗保健在过去十年中有所发展，但其有效性仍存在争议。先前一项针对退伍军人事务部（VA）团队管理的家庭初级保健（TM/HBPC）的试验发现了良好的结果，但该模式的可复制性和研究结果的普遍性尚不清楚。
评估TM/HBPC对功能状态、健康相关生活质量（HR-QoL）、护理满意度和护理成本的影响。
1994年10月至1998年9月在16个设有HBPC项目的VA医疗中心进行的多中心随机对照试验。
共有1966名平均年龄为70岁的患者，他们有2项或更多日常生活活动障碍，或患有晚期疾病、充血性心力衰竭（CHF）或慢性阻塞性肺疾病（COPD）。干预措施为家庭初级保健（n=981），包括一名初级保健经理、为患者提供24小时联系方式、提前批准医院再入院，以及HBPC团队参与出院计划，与常规VA和私营部门护理（n=985）进行对比。
患者功能状态、患者和护理人员的HR-QoL及满意度、护理人员负担、医院再入院情况以及12个月内的费用。
通过巴氏指数评估的功能状态，在晚期（P=0.40）或非晚期（严重残疾或患有CHF或COPD的患者）（P=0.17）患者中，治疗组之间没有差异。在晚期TM/HBPC患者的情感角色功能、社会功能、身体疼痛、心理健康、活力和总体健康的HR-QoL量表中观察到显著改善。团队管理的HBPC非晚期患者在6项护理满意度量表中的5项上显著提高了5至10分。TM/HBPC组晚期患者的护理人员在HR-QoL测量中，除活力和总体健康外，有显著改善。非晚期患者的护理人员在生活质量测量中有显著改善，并报告护理人员负担减轻（P=0.008）。患有严重残疾的团队管理的HBPC患者在6个月时医院再入院率相对下降了22%（TM/HBPC组为0.7次再入院/患者，对照组为0.9次再入院/患者）（P=0.03），但在12个月时未持续。TM/HBPC组在6个月时人均总费用高出6.8%（19190美元对17971美元），在12个月时高出12.1%（31401美元对28008美元）。
TM/HBPC干预改善了大多数晚期患者的HR-QoL测量指标和非晚期患者的满意度。它改善了护理人员的HR-QoL、护理满意度和护理人员负担，并在6个月时减少了医院再入院率，但它不能替代其他形式的护理。应权衡TM/HBPC较高的成本与这些益处。
