Sylvia Martha L, Griswold Michael, Dunbar Linda, Boyd Cynthia M, Park Margaret, Boult Chad
Johns Hopkins HealthCare, Glen Burnie, Maryland 21060, USA.
Dis Manag. 2008 Feb;11(1):29-36. doi: 10.1089/dis.2008.111723.
Guided Care (GC) is an enhancement to primary care that incorporates the operative principles of disease management and chronic care innovations. In a 6-month quasi-experimental study, we compared the cost and utilization patterns of patients assigned to GC and Usual Care (UC). The setting was a community-based general internal medicine practice. The participants were patients of 4 general internists. They were older, chronically ill, community-dwelling patients, members of a capitated health plan, and identified as high risk. Using the Adjusted Clinical Groups Predictive Model (ACG-PM), we identified those at highest risk of future health care utilization. We selected the 75 highest-risk older patients of 2 internists at a primary care practice to receive GC and the 75 highest-risk older patients of 2 other internists in the same practice to receive UC. Insurance data were used to describe the groups' demographics, chronic conditions, insurance expenditures, and utilization. Among our results, at baseline, the GC (all targeted patients) and UC groups were similar in demographics and prevalence of chronic conditions, but the GC group had a higher mean ACG-PM risk score (0.34 vs. 0.20, p < 0.0001). During the following 6 months, the GC group had lower unadjusted mean insurance expenditures, hospital admissions, hospital days, and emergency department visits (p > 0.05). There were larger differences in insurance expenditures between the GC and UC groups at lower risk levels (at ACG-PM = 0.10, mean difference = $4340; at ACG-PM = 0.6, mean difference = $1304). Thirty-one of the 75 patients assigned to receive GC actually enrolled in the intervention. These results suggest that GC may reduce insurance expenditures for high-risk older adults. If these results are confirmed in larger, randomized studies, GC may help to increase the efficiency of health care for the aging American population.
引导式护理（GC）是对初级护理的一种强化，它融合了疾病管理的操作原则和慢性病护理创新。在一项为期6个月的准实验研究中，我们比较了被分配到引导式护理和常规护理（UC）的患者的成本和使用模式。研究背景是一个基于社区的普通内科诊所。参与者是4位普通内科医生的患者。他们是年龄较大、患有慢性病、居住在社区的患者，是按人头付费的健康计划的成员，并且被认定为高风险人群。我们使用调整后的临床分组预测模型（ACG-PM）来确定那些未来医疗保健使用风险最高的患者。我们从一家初级护理诊所中挑选了2位内科医生的75位风险最高的老年患者接受引导式护理，以及同一家诊所另外2位内科医生的75位风险最高的老年患者接受常规护理。保险数据用于描述两组患者的人口统计学特征、慢性病状况、保险支出和使用情况。在我们的研究结果中，在基线时，引导式护理组（所有目标患者）和常规护理组在人口统计学特征和慢性病患病率方面相似，但引导式护理组的平均ACG-PM风险评分更高（0.34对0.20，p < 0.0001）。在接下来的6个月中，引导式护理组未经调整的平均保险支出、住院次数、住院天数和急诊就诊次数较低（p > 0.05）。在较低风险水平下，引导式护理组和常规护理组在保险支出方面存在更大差异（在ACG-PM = 0.10时，平均差异 = 4340美元；在ACG-PM = 0.6时，平均差异 = 1304美元）。被分配接受引导式护理的75位患者中有31位实际参与了干预。这些结果表明，引导式护理可能会降低高风险老年人群的保险支出。如果这些结果在更大规模的随机研究中得到证实，引导式护理可能有助于提高美国老年人群的医疗保健效率。
