Boult Chad, Reider Lisa, Frey Katherine, Leff Bruce, Boyd Cynthia M, Wolff Jennifer L, Wegener Stephen, Marsteller Jill, Karm Lya, Scharfstein Daniel
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
J Gerontol A Biol Sci Med Sci. 2008 Mar;63(3):321-7. doi: 10.1093/gerona/63.3.321.
The quality of health care for older Americans with multiple chronic conditions is suboptimal. We designed "Guided Care" (GC) to enhance quality of care by integrating a registered nurse, intensively trained in chronic care, into primary care practices to work with physicians in providing comprehensive chronic care to 50-60 multimorbid older patients.
We hypothesized that GC would improve the quality of health care for this population. In 2006, we began a cluster-randomized controlled trial of GC at eight practices (n = 49 physicians). Older patients of these practices were eligible to participate if they were at risk for using health services heavily during the coming year. Teams of two to five physicians and their at-risk older patients were randomized to either GC or usual care (UC). Six months after baseline, participants rated the quality of their health care by answering validated closed-ended questions from telephone interviewers who were masked to group assignment.
Of the 13,534 older patients screened, 2391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 6 months, 93.8% and 93.2% of the GC and UC participants who remained alive and eligible completed telephone interviews. GC participants were more likely than UC participants to rate their care highly (adjusted odds ratio = 2.0, 95% confidence interval, 1.2-3.4, p =.006), and primary care physicians were more likely to be satisfied with their interactions with chronically ill older patients and their families (p <.05).
GC improves important aspects of the quality of health care for multimorbid older persons. Additional data will become available as this trial continues.
患有多种慢性病的美国老年人所接受的医疗保健质量并不理想。我们设计了“引导式护理”（GC），通过将一名经过慢性病护理强化培训的注册护士纳入初级保健机构，与医生合作，为50至60名患有多种疾病的老年患者提供全面的慢性病护理，以提高护理质量。
我们假设GC能改善这一人群的医疗保健质量。2006年，我们在8家机构（49名医生）开展了一项GC的整群随机对照试验。这些机构中，预计下一年度有大量医疗服务使用风险的老年患者有资格参与。由两到五名医生及其有风险的老年患者组成的团队被随机分为GC组或常规护理（UC）组。基线期6个月后，参与者通过回答来自对分组情况不知情的电话访员的有效封闭式问题，对其医疗保健质量进行评分。
在筛查的13534名老年患者中，2391名（17.7%）有资格参与研究，其中904名（37.8%）签署知情同意书并被整群随机分组。6个月后，GC组和UC组中仍存活且符合条件的参与者分别有93.8%和93.2%完成了电话访谈。GC组参与者比UC组参与者更有可能对他们接受的护理给予高度评价（调整后的优势比=2.0，95%置信区间为1.2 - 3.4，p = 0.006），并且初级保健医生更有可能对他们与慢性病老年患者及其家属的互动感到满意（p < 0.05）。
GC改善了患有多种疾病的老年人医疗保健质量的重要方面。随着该试验的继续，将获得更多数据。
