Hung Dorothy Y, Glasgow Russell E, Dickinson L Miriam, Froshaug Desireé B, Fernald Douglas H, Balasubramanian Bijal A, Green Larry A
Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York 10032, USA.
Am J Prev Med. 2008 Nov;35(5 Suppl):S398-406. doi: 10.1016/j.amepre.2008.08.009.
The chronic care model (CCM) is a system-level framework used to guide quality improvement efforts in health care. However, little is known about its relationship to patient-level health measures. This study describes the implementation of the CCM as adapted for prevention and health behavior counseling in primary care practices, and examines relationships between the CCM and patient health measures, including general health status and health-related quality of life (HRQOL).
Baseline data from Round 2 of the Prescription for Health initiative (2005-2007) were used to assess CCM implementation in 57 practices located nationwide. Relationships between the CCM and three separate measures of health among 4735 patients were analyzed in 2007. A hierarchical generalized linear modeling approach to ordinal regression was used to estimate categories of general health status, unhealthy days, and activity-limiting days, adjusting for patient covariates and clustering effects.
Outcome variances were significantly accounted for by differences in practice characteristics (p<0.001). Practices that used individual or group planned visits were more likely to see patients in lower health categories across all measures (OR=0.74-0.81, p<0.05). Practices that used patient registries, health promotion champions, evidence-based guidelines, publicly reported performance measures, and support for behavior change were associated with higher patient health levels (OR=1.28-1.98, p<0.05).
A practice's implementation of the CCM was significantly related to patient health status and HRQOL. Adapting the CCM for prevention may serve to reorient care delivery toward more proactive behavior change and improvements in patient health outcomes.
慢性病护理模式（CCM）是一个用于指导医疗保健质量改进工作的系统级框架。然而，对于其与患者层面健康指标的关系却知之甚少。本研究描述了适用于初级保健实践中预防和健康行为咨询的CCM的实施情况，并研究了CCM与患者健康指标之间的关系，包括总体健康状况和健康相关生活质量（HRQOL）。
利用健康处方倡议第二轮（2005 - 2007年）的基线数据，评估全国范围内57个实践中的CCM实施情况。2007年分析了CCM与4735名患者的三种不同健康指标之间的关系。采用分层广义线性模型进行有序回归，以估计总体健康状况、不健康天数和活动受限天数的类别，并对患者协变量和聚类效应进行调整。
实践特征的差异显著解释了结果方差（p<0.001）。使用个体或小组计划就诊的实践在所有指标上更有可能见到健康状况较差类别的患者（OR = 0.74 - 0.81，p<0.05）。使用患者登记册、健康促进倡导者、循证指南、公开报告的绩效指标以及对行为改变的支持的实践与较高的患者健康水平相关（OR = 1.28 - 1.98，p<0.05）。
实践中CCM的实施与患者健康状况和HRQOL显著相关。将CCM应用于预防可能有助于使护理服务重新定位，朝着更积极的行为改变和改善患者健康结果的方向发展。
