Cambridge Centre for Health Services Research, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK.
Int J Integr Care. 2012 Jul 24;12:e130. doi: 10.5334/ijic.850. Print 2012 Jul-Sep.
In 2009, the English Department of Health appointed 16 integrated care pilots which aimed to provide better integrated care. We report the quantitative results from a multi-method evaluation of six of the demonstration projects which used risk profiling tools to identify older people at risk of emergency hospital admission, combined with intensive case management for people identified as at risk. The interventions focused mainly on delivery system redesign and improved clinical information systems, two key elements of Wagner's Chronic Care Model.
Questionnaires to staff and patients. Difference-in-differences analysis of secondary care utilisation using data on 3646 patients and 17,311 matched controls, and changes in overall secondary care utilisation.
Most staff thought that care for their patients had improved. More patients reported having a care plan but they found it significantly harder to see a doctor or nurse of their choice and felt less involved in decisions about their care. Case management interventions were associated with a 9% increase in emergency admissions. We found some evidence of imbalance between cases and controls which could have biased this estimate, but simulations of the possible effect of unobserved confounders showed that it was very unlikely that the sites achieved their goal of reducing emergency admissions. However, we found significant reductions of 21% and 22% in elective admissions and outpatient attendance in the six months following an intervention, and overall inpatient and outpatient costs were significantly reduced by 9% during this period. Area level analyses of whole practice populations suggested that overall outpatient attendances were significantly reduced by 5% two years after the start of the case management schemes.
Case management may result in improvements in some aspects of care and has the potential to reduce secondary care costs. However, to improve patient experience, case management approaches need to be introduced in a way which respects patients' wishes, for example the ability to see a familiar doctor or nurse.
2009 年，英国卫生部任命了 16 个综合护理试点项目，旨在提供更好的综合护理。我们报告了对其中六个示范项目的多方法评估的定量结果，这些项目使用风险分析工具来识别有急诊住院风险的老年人，并对被识别为有风险的患者进行强化病例管理。这些干预措施主要集中在交付系统的重新设计和改进临床信息系统，这是瓦格纳慢性病护理模式的两个关键要素。
对员工和患者进行问卷调查。使用 3646 名患者和 17311 名匹配对照的二级护理利用数据进行差异-差异分析，以及整体二级护理利用的变化。
大多数员工认为他们对患者的护理有所改善。更多的患者报告有护理计划，但他们发现看医生或护士的选择更加困难，并且对护理决策的参与感降低。病例管理干预与急诊入院增加 9%相关。我们发现病例和对照组之间存在一些不平衡的证据，这可能会使这个估计产生偏差，但对未观察到的混杂因素的可能影响的模拟表明，这些站点非常不可能实现减少急诊入院的目标。然而，我们发现干预后六个月内选择性入院和门诊就诊显著减少 21%和 22%，在此期间总住院和门诊费用显著减少 9%。整个实践人群的区域水平分析表明，病例管理计划启动两年后，总门诊就诊量显著减少 5%。
病例管理可能会改善护理的某些方面，并有可能降低二级护理成本。然而，为了改善患者体验，病例管理方法需要以尊重患者意愿的方式引入，例如能够看到熟悉的医生或护士的能力。
