Young Wendy, Rewa George, Goodman Shaun G, Jaglal Susan Brenda, Cash Linda, Lefkowitz Charles, Coyte Peter C
Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Ont.
CMAJ. 2003 Oct 28;169(9):905-10.
Disease management programs (DMPs) that use multidisciplinary teams and specialized clinics reduce hospital admissions and improve quality of life and functional status. Evaluations of cardiac DMPs delivered by home health nurses are required.
Between August 1999 and August 2000 we identified consecutive patients admitted to hospital with elevated cardiac enzymes. Patients who agreed were randomly assigned to participate in a DMP or to receive usual care. The DMP included 6 home visits by a cardiac-trained nurse, a standardized nurses' checklist, referral criteria for specialty care, communication with the family physician and patient education. We measured readmission days per 1000 follow-up days for angina, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD); all-cause readmission days; and provincial claims for emergency department visits, physician visits, diagnostic or therapeutic services and laboratory services.
We screened 715 consecutive patients admitted with elevated cardiac markers between August 1999 and August 2000. Of those screened 71 DMP and 75 usual care patients met the diagnostic criteria for myocardial infarction, were eligible for visits from a home health nurse and consented to participate in the study. Readmission days for angina, CHF and COPD per 1000 follow-up days were significantly higher for usual care patients than for DMP patients (incidence density ratio [IDR] = 1.59, 95% confidence interval [CI] 1.27-2.00, p < 0.001). All-cause readmission days per 1000 follow-up days were significantly higher for usual care patients than for DMP patients (IDR = 1.53, 95% CI 1.37-1.71, p < 0.001). The difference in emergency department encounters per 1000 follow-up days was significant (IDR = 2.08, 95% CI 1.56-2.77, p < 0.001). During the first 25 days after discharge, there were significantly fewer provincial claims submitted for DMP patients than for usual care patients for emergency department visits (p = 0.007), diagnostic or therapeutic services (p = 0.012) and laboratory services (p = 0.007).
The results provide evidence that an appropriately developed and implemented community-based inner-city DMP delivered by home health nurses has a positive impact on patient outcomes.
使用多学科团队和专科诊所的疾病管理项目（DMPs）可减少住院次数，并改善生活质量和功能状态。需要对由家庭健康护士实施的心脏疾病管理项目进行评估。
在1999年8月至2000年8月期间，我们确定了连续入院且心肌酶升高的患者。同意参与的患者被随机分配参加疾病管理项目或接受常规护理。该疾病管理项目包括由经过心脏护理培训的护士进行6次家访、一份标准化的护士检查表、专科护理转诊标准、与家庭医生沟通以及患者教育。我们测量了每1000个随访日内心绞痛、充血性心力衰竭（CHF）和慢性阻塞性肺疾病（COPD）的再入院天数；全因再入院天数；以及省级急诊科就诊、医生诊疗、诊断或治疗服务及实验室服务的费用报销情况。
我们筛查了1999年8月至2000年8月期间连续入院且心肌标志物升高的715例患者。在这些被筛查的患者中，71例疾病管理项目患者和75例常规护理患者符合心肌梗死诊断标准，有资格接受家庭健康护士家访并同意参与研究。常规护理患者每1000个随访日内心绞痛、CHF和COPD的再入院天数显著高于疾病管理项目患者（发病密度比[IDR]=1.59，95%置信区间[CI]1.27 - 2.00，p<0.001）。常规护理患者每1000个随访日的全因再入院天数显著高于疾病管理项目患者（IDR = 1.53，95% CI 1.37 - 1.71，p<0.001）。每1000个随访日急诊科就诊次数的差异具有统计学意义（IDR = 2.08，95% CI 1.56 - 2.77，p<0.001）。出院后的前25天内，疾病管理项目患者提交的省级急诊科就诊（p = 0.007）、诊断或治疗服务（p = 0.012）及实验室服务（p = 0.007）费用报销申请显著少于常规护理患者。
结果表明，由家庭健康护士适当制定和实施的基于社区的市中心疾病管理项目对患者预后有积极影响。
