Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, Australia.
Clin Gastroenterol Hepatol. 2013 Jul;11(7):850-8.e1-4. doi: 10.1016/j.cgh.2013.01.014. Epub 2013 Jan 29.
BACKGROUND & AIMS: Despite the economic impacts of chronic liver failure (CLF) and the success of chronic disease management (CDM) programs in routine clinical practice, there have been no randomized controlled trials of CDM for CLF. We investigated the efficacy of CDM programs for CLF patients in a prospective, controlled trial.
Sixty consecutive patients with cirrhosis and complications from CLF were assigned randomly to groups given intervention (n = 40) or usual care (n = 20), from 2009 to 2010. The 12-month intervention comprised 4 CDM components: delivery system redesign, self-management support, decision support, and clinical information systems. The primary outcome was the number of days spent in a hospital bed for liver-related reasons. Secondary outcomes were rates of other hospital use measures, rate of attendance at planned outpatient care, disease severity, quality of life, and quality of care.
The intervention did not reduce the number of days patients spent in hospital beds for liver-related reasons, compared with usual care (17.8 vs 11.0 bed days/person/y, respectively; incidence rate ratio, 1.6; 95% confidence interval, 0.5-4.8; P = .39), or affect other measures of hospitalization. Patients given the intervention had a 30% higher rate of attendance at outpatient care (incidence rate ratio, 1.3; 95% confidence interval, 1.1-1.5; P = .004) and significant increases in quality of care, based on adherence to hepatoma screening, osteoporosis and vaccination guidelines, and referral to transplant centers (P < .05 for all).
In a pilot study to determine the efficacy of CDM for patients with CLF, patients receiving CDM had significant increases in attendance at outpatient centers and quality of care, compared with patients who did not receive CDM. However, CDM did not appear to reduce hospital admission rates or disease severity or improve patient quality of life. Larger trials with longer follow-up periods are required to confirm these findings and assess cost effectiveness.
尽管慢性肝衰竭（CLF）的经济影响以及慢性病管理（CDM）计划在常规临床实践中的成功，但尚未有针对 CLF 的 CDM 的随机对照试验。我们在一项前瞻性对照试验中研究了 CLF 患者的 CDM 计划的疗效。
2009 年至 2010 年，连续纳入 60 例肝硬化合并 CLF 并发症的患者，随机分为干预组（n=40）和常规护理组（n=20）。为期 12 个月的干预措施包括 4 个 CDM 组成部分：交付系统重新设计、自我管理支持、决策支持和临床信息系统。主要结局是因肝脏相关原因住院的天数。次要结局是其他住院使用措施的发生率、计划门诊护理的就诊率、疾病严重程度、生活质量和护理质量。
与常规护理相比，干预组并未减少因肝脏相关原因住院的天数（分别为 17.8 天和 11.0 天/人/年；发病率比，1.6；95%置信区间，0.5-4.8；P=.39），也未影响其他住院措施。接受干预的患者门诊就诊率提高了 30%（发病率比，1.3；95%置信区间，1.1-1.5；P=.004），并且根据肝癌筛查、骨质疏松症和疫苗接种指南以及转诊到移植中心的依从性，护理质量显著提高（所有 P 值均<.05）。
在一项针对 CLF 患者 CDM 疗效的初步研究中，与未接受 CDM 的患者相比，接受 CDM 的患者门诊就诊率和护理质量显著提高。然而，CDM 似乎并未降低住院率或疾病严重程度，也未改善患者的生活质量。需要更大规模、随访时间更长的试验来证实这些发现并评估成本效益。
