Juster Iver A
Active Health Management, Inc., New York, New York 10016, USA.
Dis Manag. 2005 Jun;8(3):188-97. doi: 10.1089/dis.2005.8.188.
Due to patient or physician factors, people with chronic diseases frequently do not receive evidence-based care. While a physician-directed claims-based alerting system targeting gaps in care was previously shown to increase resolution of specific clinical issues, many apparently relevant issues remained unresolved. The purpose of this research was to demonstrate that adding member interaction with a nurse to a physician alerting system can uncover additional care gaps beyond those identified by a claims, prescription, and lab results-based alerting system, and increase successful resolution of alerts by communicating care gaps to members. An opt-in nurse-managed pilot program focusing on identification and resolution of specific clinical issues was implemented for 205,463 members of self-insured health plans that had been utilizing the claims-based physician alerting system. Specific clinical issues identified by the claims-based system were communicated to both program enrollees and physicians, and new clinical issues were identified based on nurse-directed participant feedback. Participants were encouraged to discuss issues with their physicians. Issue resolution rates were tracked using subsequent claims, pharmacy, and lab data. At 1 year, we studied the rate of new clinical issue identification and compared the program's resolution rate of claims-identifiable issues to that of non-enrollees. While program participants accounted for 0.65% of total member-months in the pilot year, they triggered 4.82% (644) of the population's claims-based clinical alerts, and an additional 514 alerts from data based on participant-supplied data--80.8% more than claims/pharmacy/lab-generated alerts. Of the participants' claims-based alerts, 207 (32.1%) showed claims/lab evidence of successful resolution, compared with 3,380 of 12,714 (26.6%) for non-participants, a 20.9% increase in resolutions (chi2 = 9.8, p < 0.01). Care management technology complemented by a nurse-directed interactive program increased the rate of identification of clinical issues compared to claims alerts alone. Use of this program to communicate specific issues to both patients and physicians significantly increased the rate of issue resolution.
由于患者或医生因素，慢性病患者常常无法获得循证护理。虽然之前有研究表明，针对护理缺口的医生主导的基于索赔的警报系统可提高特定临床问题的解决率，但许多明显相关的问题仍未得到解决。本研究的目的是证明，在医生警报系统中增加护士与会员的互动，能够发现基于索赔、处方和实验室结果的警报系统所未识别出的更多护理缺口，并通过将会员护理缺口告知会员来提高警报的成功解决率。针对205,463名使用基于索赔的医生警报系统的自保健康计划会员，实施了一项专注于识别和解决特定临床问题的自愿参与的护士管理试点项目。基于索赔系统识别出的特定临床问题会同时告知项目参与者和医生，并根据护士指导的参与者反馈来识别新的临床问题。鼓励参与者与他们的医生讨论这些问题。使用后续的索赔、药房和实验室数据来跟踪问题解决率。在1年时，我们研究了新临床问题的识别率，并将该项目对可通过索赔识别的问题的解决率与未参与者的解决率进行了比较。虽然项目参与者在试点年度占会员总月数的0.65%，但他们触发了该人群基于索赔的临床警报的4.82%（644次），以及基于参与者提供的数据的另外514次警报——比索赔/药房/实验室生成的警报多80.8%。在参与者基于索赔的警报中, 207次（32.1%）显示有索赔/实验室证据表明问题得到成功解决，而非参与者在12,714次警报中有3,380次（26,6%）得到解决，解决率提高了20.9%（卡方 = 9.8，p < 0.01）。与仅靠索赔警报相比，由护士指导的互动项目辅助的护理管理技术提高了临床问题的识别率。使用该项目将会员护理缺口告知患者和医生，显著提高了问题解决率。
