Boult Chad, Reider Lisa, Leff Bruce, Frick Kevin D, Boyd Cynthia M, Wolff Jennifer L, Frey Katherine, Karm Lya, Wegener Stephen T, Mroz Tracy, Scharfstein Daniel O
Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Room 693, Baltimore, MD 21205, USA.
Arch Intern Med. 2011 Mar 14;171(5):460-6. doi: 10.1001/archinternmed.2010.540.
The effect of interdisciplinary primary care teams on the use of health services by patients with multiple chronic conditions is uncertain. This study aimed to measure the effect of guided care teams on multimorbid older patients' use of health services.
Eligible patients from 3 health care systems in the Baltimore, Maryland-Washington, DC, area were cluster-randomized to receive guided care or usual care for 20 months between November 1, 2006, and June 30, 2008. Eight services of a guided care nurse working in partnership with patients' primary care physicians were provided: comprehensive assessment, evidence-based care planning, monthly monitoring of symptoms and adherence, transitional care, coordination of health care professionals, support for self-management, support for family caregivers, and enhanced access to community services. Outcome measures were frequency of use of emergency departments, hospitals, skilled nursing facilities, home health agencies, primary care physician services, and specialty physician services.
The study included 850 older patients at high risk for using health care heavily in the future. The only statistically significant overall effect of guided care in the whole sample was a reduction in episodes of home health care (odds ratio, 0.70; 95% confidence interval, 0.53-0.93). In a preplanned analysis, guided care also reduced skilled nursing facility admissions (odds ratio, 0.53; 95% confidence interval, 0.31-0.89) and days (0.48; 0.28-0.84) among Kaiser-Permanente patients.
Guided care reduces the use of home health care but has little effect on the use of other health services in the short run. Its positive effect on Kaiser-Permanente patients' use of skilled nursing facilities and other health services is intriguing. Trial Registration clinicaltrials.gov Identifier: NCT00121940.
跨学科初级保健团队对患有多种慢性病的患者使用卫生服务的影响尚不确定。本研究旨在衡量引导式护理团队对患有多种疾病的老年患者使用卫生服务的影响。
2006年11月1日至2008年6月30日期间，来自马里兰州巴尔的摩-华盛顿特区地区3个医疗系统的符合条件的患者被整群随机分组，接受为期20个月的引导式护理或常规护理。提供了八项由引导式护理护士与患者的初级保健医生合作开展的服务：全面评估、循证护理计划、症状和依从性的每月监测、过渡性护理、医疗保健专业人员的协调、自我管理支持、家庭护理人员支持以及增加社区服务的可及性。结局指标为急诊科、医院、专业护理机构、家庭健康机构、初级保健医生服务和专科医生服务的使用频率。
该研究纳入了850名未来大量使用医疗保健的高风险老年患者。在整个样本中，引导式护理唯一具有统计学意义的总体效果是家庭健康护理次数减少（优势比，0.70；95%置信区间，0.53 - 0.93）。在一项预先计划的分析中，引导式护理还减少了凯撒医疗集团患者入住专业护理机构的次数（优势比，0.53；95%置信区间，0.31 - 0.89）和天数（0.48；0.28 - 0.84）。
引导式护理减少了家庭健康护理的使用，但短期内对其他卫生服务的使用影响不大。其对凯撒医疗集团患者使用专业护理机构及其他卫生服务的积极影响很有趣。试验注册clinicaltrials.gov标识符：NCT00121940。
