Mills Peter D, Harvey Peter W
Eyre Peninsula Division of General Practice and Adelaide University, South Australia.
Aust J Rural Health. 2003 Jun;11(3):131-7.
This article describes the patient management processes developed during the Council of Australian Governments (COAG) coordinated care trial and use of health outcome measures to monitor changes in utilisation patterns and patient well-being over time for a subgroup of 398 patients with type 2 diabetes.
The Eyre component of the South Australian (SA) HealthPlus coordinated care trial was a matched geographically controlled study in which the outcomes for the intervention group of 1350 patients were compared with those of a similar control group of 500 patients in another rural health region in SA.
The trial was carried out on Eyre Peninsula in SA across populations in rural communities and in the main centres of Whyalla, Port Lincoln and Ceduna. Care planning was organised through general practitioner practices and services negotiated with allied health services and hospitals to meet patient needs.
The SA HealthPlus trial included 1350 patients with chronic and complex illness. A subset of this group comprising 398 patients with type 2 diabetes is described in this report. Patients recruited into the three-year trial were care planned using a patient centred care planning model through which patient goals were generated along with medical management goals developed by clinicians and primary health care professionals. Relevant health services were scheduled in line with best practice and care plans were reviewed each year. Patient service utilisation, progress towards achieving health related goals and patient health outcomes were recorded and assessed to determine improvements in health and well-being along with the cost and profile of the services provided.
Significant numbers of patients experienced improved health outcomes as a consequence of their involvement in the trial, and utilisation data showed reductions in hospital and medical expenditure for some patients. These results suggest that methods applied in the SA HealthPlus coordinated care trial have led to improvements in health outcomes for patients with diabetes and other chronic illnesses. In addition, the processes associated with the COAG trial motivated significant organisational change in the Regional Health Service as well as providing an opportunity to study the health and well-being outcomes resulting from a major community health intervention.
The importance of the SA HealthPlus trial has been the demonstrated link between a formal research trial and significant developments in the larger health system with the trial not only leading to improvements in clinical outcomes for patients, but also acting as a catalyst for organisational reform. We now need to look beyond the illness focus of health outcome research to develop population based health approaches to improving overall community well-being.
本文描述了在澳大利亚政府理事会（COAG）协调护理试验期间制定的患者管理流程，以及使用健康结果指标来监测398例2型糖尿病患者亚组随时间推移的使用模式变化和患者健康状况。
南澳大利亚州（SA）HealthPlus协调护理试验的艾尔地区部分是一项地理匹配对照研究，其中将1350例患者的干预组结果与SA另一个农村卫生区域的500例类似对照组患者的结果进行比较。
该试验在SA的艾尔半岛农村社区以及主要中心城市怀阿拉、林肯港和塞杜纳的人群中开展。通过全科医生诊所组织护理计划，并与联合健康服务机构和医院协商服务，以满足患者需求。
SA HealthPlus试验纳入了1350例患有慢性和复杂疾病的患者。本报告描述了该组中的一个子集，即398例2型糖尿病患者。纳入为期三年试验的患者采用以患者为中心的护理计划模型进行护理计划制定，通过该模型确定患者目标以及临床医生和初级卫生保健专业人员制定的医疗管理目标。根据最佳实践安排相关健康服务，并且每年对护理计划进行审查。记录并评估患者服务利用情况、实现健康相关目标的进展以及患者健康结果，以确定健康和幸福状况的改善情况以及所提供服务的成本和概况。
大量患者因参与试验而健康结果得到改善，利用数据显示部分患者的住院和医疗支出有所减少。这些结果表明，SA HealthPlus协调护理试验中应用的方法已使糖尿病和其他慢性疾病患者的健康结果得到改善。此外，与COAG试验相关的流程推动了地区卫生服务机构的重大组织变革，同时也提供了一个机会来研究重大社区健康干预所带来的健康和幸福结果。
SA HealthPlus试验的重要性在于证明了正式研究试验与更大的卫生系统中的重大发展之间的联系，该试验不仅使患者的临床结果得到改善，还成为组织改革的催化剂。我们现在需要超越健康结果研究对疾病的关注，制定基于人群的健康方法来改善社区整体福祉。
