Fenton Joshua J, Levine Martin D, Mahoney Lisa D, Heagerty Patrick J, Wagner Edward H
Department of Family and Community Medicine, University of California, Davis, Sacramento, CA 95817, USA.
J Am Board Fam Med. 2006 Jul-Aug;19(4):331-9. doi: 10.3122/jabfm.19.4.331.
Frail elders often receive low-quality primary care, yet the optimal role of geriatricians in primary care settings remains uncertain. We evaluated the health utilization impacts of an innovative intervention emphasizing chronic disease self-management and physical activity promotion among frail elders in primary care.
The intervention was implemented within two primary care practices at a single clinic serving a large population of frail elders enrolled in a western Washington health plan. Subjects included older patients (age >or=65 years) with disproportionate baseline outpatient service use who attended two on-site visits with a geriatrician during which each received comprehensive assessment and a problem-solving intervention to enhance chronic disease self-management and promote physical activity (N = 146). Our evaluation had a retrospective matched cohort design. Controls receiving primary care at other health plan clinics were matched 3:1 to intervention subjects by sex and a propensity score (N = 437), which was computed using demographic, clinical, and health care utilization factors that were predictive of attending the intervention. Among intervention subjects and controls following the intervention, we compared relative rates of hospitalization, outpatient and specialty visits, nursing home admission, mortality, and prescription of selected high-risk medications, as well as total health care costs.
From March 2002 to November 2003, the geriatrician evaluated 146 of 725 elderly subjects (20%) in the two primary care practices. During a mean follow-up of 1.3 years, intervention subjects had a reduced rate of hospitalization relative to matched controls (incidence rate ratio 0.57; 95% CI: 0.37 to 0.86; P < .01). Intervention and control subjects did not have significantly different rates of specialty visits, outpatient visits, nursing home admission, mortality, or high-risk prescriptions. Relative to matched controls during follow-up, total health care costs were 26.3% lower among intervention subjects (95% CI: 1.3%, 44.9%; P = .04).
Outpatient geriatric interventions emphasizing collaboration between geriatricians and primary care physicians, chronic disease self-management, and physical activity may reduce hospitalization risk and total health care costs among vulnerable elders.
体弱的老年人常常接受低质量的初级保健，然而老年病医生在初级保健环境中的最佳作用仍不明确。我们评估了一项创新干预措施对初级保健中体弱老年人的健康利用影响，该干预措施强调慢性病自我管理和身体活动促进。
该干预措施在一家为大量参加华盛顿西部健康计划的体弱老年人服务的单一诊所的两个初级保健机构中实施。受试者包括年龄≥65岁、基线门诊服务使用不成比例的老年患者，他们接受了老年病医生的两次现场就诊，期间每人都接受了全面评估和解决问题的干预措施，以加强慢性病自我管理和促进身体活动（N = 146）。我们的评估采用回顾性匹配队列设计。在其他健康计划诊所接受初级保健的对照组按性别和倾向得分与干预组受试者以3:1的比例进行匹配（N = 437），倾向得分是使用预测参加干预的人口统计学、临床和医疗保健利用因素计算得出的。在干预后，我们比较了干预组受试者和对照组之间的住院、门诊和专科就诊、养老院入院、死亡率以及选定高风险药物处方的相对发生率，以及总医疗保健费用。
2002年3月至2003年11月，老年病医生对两个初级保健机构中725名老年受试者中的146名（20%）进行了评估。在平均1.3年的随访期间，干预组受试者相对于匹配对照组的住院率有所降低（发病率比0.57；95%可信区间：0.37至0.86；P <.01）。干预组和对照组在专科就诊、门诊就诊、养老院入院、死亡率或高风险处方方面的发生率没有显著差异。与随访期间的匹配对照组相比，干预组受试者的总医疗保健费用低26.3%（95%可信区间：1.3%，44.9%；P =.04）。
强调老年病医生与初级保健医生合作、慢性病自我管理和身体活动的门诊老年病干预措施可能会降低脆弱老年人的住院风险和总医疗保健费用。
