Bodenheimer Thomas, Wang Margaret C, Rundall Thomas G, Shortell Stephen M, Gillies Robin R, Oswald Nancy, Casalino Lawrence, Robinson James C
Department of Family and Community Medicine, University of California at San Francisco, USA.
Jt Comm J Qual Saf. 2004 Sep;30(9):505-14. doi: 10.1016/s1549-3741(04)30059-6.
Care management processes (CMPs) such as disease registries, reminder systems, performance feedback, case management, and self-management education can improve chronic illness care, yet 50% of physician organizations have instituted few if any CMPs.
Site-visit interviews were conducted with 158 leaders at 15 physician organizations, with 3 organizations (1 large medical group, 1 small medical group, and 1 independent practice association [IPA]) chosen randomly in most cases in each of five communities.
Seven of the 15 organizations had implemented CMPs minimally or not at all. CMPs were most common for diabetes and least common for depression; no IPAs had achieved significant CMP implementation for any of the conditions. The two most commonly mentioned facilitators were strong leadership and organizational culture valuing quality. The top five barriers were poor financial situation, reimbursement that does not reward high quality, inadequate information technology, physician resistance, and physicians being too busy.
Strong leadership and a quality-valuing culture are important facilitators of improved chronic care, but if insurers do not reward chronic care improvement, it is unlikely that CMPs will become permanently institutionalized in physician organizations.
诸如疾病登记、提醒系统、绩效反馈、病例管理和自我管理教育等护理管理流程（CMPs）能够改善慢性病护理，但50%的医师组织几乎未设立任何CMPs。
对15个医师组织的158名负责人进行了实地访问访谈，在五个社区的大多数情况下，每个社区随机选择3个组织（1个大型医疗集团、1个小型医疗集团和1个独立执业协会[IPA]）。
15个组织中有7个最少实施或根本未实施CMPs。CMPs在糖尿病管理中最为常见，在抑郁症管理中最不常见；没有IPA在任何疾病管理中实现显著的CMP实施。最常提到的两个促进因素是强有力的领导和重视质量的组织文化。前五大障碍是财务状况不佳、不奖励高质量的报销政策、信息技术不足、医师抵触以及医师太忙。
强有力的领导和重视质量的文化是改善慢性病护理的重要促进因素，但如果保险公司不奖励慢性病护理的改善，CMPs不太可能在医师组织中永久制度化。
