Greenberg Greg A, Rosenheck Robert A
Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut, USA.
Psychiatr Serv. 2005 Apr;56(4):427-33. doi: 10.1176/appi.ps.56.4.427.
Continuity of care is widely viewed as a key quality indicator for outpatient mental health care. However, few studies have been conducted of the relationship between continuity of care and client outcomes. This study examined the relationship between measures of three aspects of continuity of care (regularity of care, continuity of treatment across organizational boundaries, and intensity of treatment) and the Global Assessment of Functioning (GAF), a single-item mental health status measure, in a national health care system.
Three analytic samples were derived from a nationwide Department of Veterans Affairs administrative data set: patients with at least one inpatient GAF rating and a later outpatient GAF rating (N=8,334) and two groups who had at least two outpatient GAF ratings, one group that was beginning a new episode of treatment (N=49,946) and a second group in ongoing treatment (N=123,371). Hierarchical linear modeling was used to control for potential site-level autocorrelation and to adjust for differences in diagnostic status, sociodemographic characteristics, baseline GAF score, and the length of time between GAF ratings.
Several positive and significant relationships were found for discharged inpatients and new outpatients. However, only a few of these relationships could be confidently said to be clinically meaningful. Specifically, among discharged inpatients, for every additional month in which an outpatient visit occurred over a six-month period, there was a .69 increase in the GAF change score for a total increase of 4.1 points. Among new outpatients the equivalent values were smaller, at .3 and 1.8. In contrast with the findings for discharged inpatients and new outpatients, high intensity of care was negatively associated with GAF change scores for continuing outpatients.
In contrast with several earlier studies, this study showed positive and statistically significant associations between several continuity-of-care measures and client outcomes. These relationships were observed only in transitional treatment situations, that is, after hospital discharge and at the beginning an episode of outpatient care, situations in which continuity of care may be especially important. However, although positive and statistically significant, the magnitude of these effects may not have been clinically meaningful.
连续性护理被广泛视为门诊心理健康护理的一项关键质量指标。然而，关于连续性护理与服务对象结局之间的关系，所开展的研究甚少。本研究在一个国家医疗保健系统中，考察了连续性护理三个方面的衡量指标（护理的规律性、跨组织边界的治疗连续性以及治疗强度）与功能总体评定量表（GAF，一项单一项目的心理健康状况衡量指标）之间的关系。
从全国退伍军人事务部的行政数据集中获取了三个分析样本：至少有一次住院GAF评分及随后一次门诊GAF评分的患者（N = 8334），以及至少有两次门诊GAF评分的两组患者，一组是开始新的治疗阶段的患者（N = 49946），另一组是正在接受治疗的患者（N = 123371）。采用分层线性模型来控制潜在的机构层面自相关性，并对诊断状态、社会人口学特征、基线GAF评分以及GAF评分之间的时间间隔差异进行调整。
在出院的住院患者和新的门诊患者中发现了若干正向且显著的关系。然而，这些关系中只有少数可以有把握地说是具有临床意义的。具体而言，在出院的住院患者中，在六个月期间每多进行一次门诊就诊，GAF变化评分就增加0.69，总共增加4.1分。在新的门诊患者中，相应的数值较小，分别为0.3和1.8。与出院的住院患者和新的门诊患者的研究结果形成对比的是，高护理强度与继续接受治疗的门诊患者的GAF变化评分呈负相关。
与一些早期研究不同，本研究显示若干连续性护理措施与服务对象结局之间存在正向且具有统计学意义的关联。这些关系仅在过渡性治疗情境中观察到，即出院后以及门诊护理阶段开始时，在这些情境中连续性护理可能尤为重要。然而尽管这些影响是正向且具有统计学意义的，但其程度可能并无临床意义。
