Department of Health Policy and Management, Bloomberg School of Public Health, Baltimore, MD 21205, USA.
J Am Geriatr Soc. 2009 Dec;57(12):2328-37. doi: 10.1111/j.1532-5415.2009.02571.x.
The quality of chronic care in America is low, and the cost is high. To help inform efforts to overhaul the ailing U.S. healthcare system, including those related to the "medical home," models of comprehensive health care that have shown the potential to improve the quality, efficiency, or health-related outcomes of care for chronically ill older persons were identified. Using multiple indexing terms, the MEDLINE database was searched for articles published in English between January 1, 1987, and May 30, 2008, that reported statistically significant positive outcomes from high-quality research on models of comprehensive health care for older persons with chronic conditions. Each selected study addressed a model of comprehensive health care; was a meta-analysis, systematic review, or trial with an equivalent concurrent control group; included an adequate number of representative, chronically ill participants aged 65 and older; used valid measures; used reliable methods of data collection; analyzed data rigorously; and reported significantly positive effects on the quality, efficiency, or health-related outcomes of care. Of 2,714 identified articles, 123 (4.5%) met these criteria. Fifteen models have improved at least one outcome: interdisciplinary primary care (1), models that supplement primary care (8), transitional care (1), models of acute care in patients' homes (2), nurse-physician teams for residents of nursing homes (1), and models of comprehensive care in hospitals (2). Policy makers and healthcare leaders should consider including these 15 models of health care in plans to reform the U.S. healthcare system. The Centers for Medicare and Medicaid Services would need new statutory flexibility to pay for care by the nurses, social workers, pharmacists, and physicians who staff these promising models.
美国的慢性病护理质量低，成本高。为了帮助改进美国病态的医疗体系，包括与“医疗之家”相关的改革，确定了综合医疗保健模式，这些模式显示出有可能提高慢性病老年患者的护理质量、效率或健康相关结果。使用多个索引术语，在 MEDLINE 数据库中搜索了 1987 年 1 月 1 日至 2008 年 5 月 30 日期间发表的英文文章，这些文章报道了高质量研究对慢性病老年患者综合医疗保健模式的统计显著积极结果。每个选定的研究都涉及综合医疗保健模式；是一项荟萃分析、系统评价或具有等效同期对照组的试验；纳入了足够数量的有代表性的、患有慢性病的 65 岁及以上参与者；使用了有效的测量方法；使用了可靠的数据收集方法；严格分析了数据；并报告了对护理质量、效率或健康相关结果的显著积极影响。在确定的 2714 篇文章中，有 123 篇（4.5%）符合这些标准。有 15 种模式至少改善了一个结果：跨学科的初级保健（1）、补充初级保健的模式（8）、过渡性护理（1）、患者家中急性护理模式（2）、疗养院居民的护士-医师团队（1）以及医院综合护理模式（2）。政策制定者和医疗保健领导者应该考虑将这 15 种医疗保健模式纳入改革美国医疗体系的计划中。医疗保险和医疗补助服务中心需要新的法定灵活性，以便为这些有前途的模式配备的护士、社会工作者、药剂师和医生支付护理费用。
