Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts2Massachusetts Veterans' Epidemiology Research and Information Center, Veterans Affairs Boston Healthcare System, Boston3Harvard Medical School, Boston.
Healthcare Financing and Economics, Veterans Affairs Boston Healthcare System, Boston, Massachusetts5Boston University School of Medicine and School of Public Health, Boston, Massachusetts.
JAMA Intern Med. 2014 Nov;174(11):1796-803. doi: 10.1001/jamainternmed.2014.4327.
Primary care services based at home have the potential to reduce the likelihood of hospitalization among older adults with multiple chronic diseases.
To characterize the association between enrollment in Home-Based Primary Care (HBPC), a national home care program operated by the US Department of Veterans Affairs (VA), and hospitalizations owing to an ambulatory care-sensitive condition among older veterans with diabetes mellitus.
Retrospective cohort study. Patients admitted to VA and non-VA hospitals were followed up from January 1, 2006, through December 31, 2010.
Veterans 67 years or older who were fee-for-service Medicare beneficiaries, were diagnosed as having diabetes mellitus and at least 1 other chronic disease, and had at least 1 admission to a VA or non-VA hospital in 2005 or 2006.
Enrollment in HBPC, defined as a minimum of 2 HBPC encounters during the study period.
Admission to VA and non-VA hospitals owing to an ambulatory care-sensitive condition, as measured by the Agency for Healthcare Research and Quality's Prevention Quality Indicators in VA medical records and Medicare claims. Outcomes were analyzed using distance from the veteran's residence to a VA facility that provides HBPC as an instrumental variable.
Among 56 608 veterans, 1978 enrolled in HBPC. These patients were older (mean age, 79.1 vs 77.1 years) and had more chronic diseases (eg, 59.2% vs 53.5% had congestive heart failure). Multivariable predictors for HBPC enrollment included paralysis (odds ratio [OR], 2.11; 95% CI, 1.63-2.74), depression (OR, 1.99; 95% CI, 1.70-2.34), congestive heart failure (OR, 1.36; 95% CI, 1.17-1.58), and distance from the nearest HBPC-providing VA facility (OR, 0.59; 95% CI, 0.50-0.70 for >10-30 vs <5 miles). After controlling for selection using an instrumental variable analysis, HBPC was associated with a significant reduction in the probability of experiencing a hospitalization owing to an ambulatory care-sensitive condition (hazard ratio, 0.71; 95% CI, 0.57-0.89), with an absolute reduction in the probability of hospitalization of 5.8% in 1 year.
Home-Based Primary Care is associated with a decreased probability of ambulatory care-sensitive condition hospitalization among elderly veterans with diabetes mellitus. In accountable care models, HBPC may have an important role in the management of older adults with multiple chronic diseases.
以家庭为基础的初级保健服务有可能降低患有多种慢性病的老年人住院的可能性。
描述 Home-Based Primary Care（HBPC）（美国退伍军人事务部（VA）运营的一项全国性家庭护理计划）与老年糖尿病患者因门诊护理敏感条件而住院之间的关联。
回顾性队列研究。从 2006 年 1 月 1 日至 2010 年 12 月 31 日，对入住 VA 和非 VA 医院的患者进行随访。
67 岁或以上的退伍军人，他们是自费医疗保险受益人，被诊断患有糖尿病和至少 1 种其他慢性病，并且在 2005 年或 2006 年至少有 1 次入住 VA 或非 VA 医院。
HBPC 的参与，定义为在研究期间至少有 2 次 HBPC 就诊。
退伍军人因门诊护理敏感条件而入住 VA 和非 VA 医院，这是通过退伍军人医疗记录和医疗保险索赔中的医疗保健研究和质量局的预防质量指标来衡量的。使用退伍军人住所到提供 HBPC 的 VA 设施的距离作为工具变量来分析结果。
在 56608 名退伍军人中，有 1978 人参加了 HBPC。这些患者年龄较大（平均年龄为 79.1 岁 vs 77.1 岁），患有更多的慢性疾病（例如，59.2% vs 53.5%患有充血性心力衰竭）。HBPC 参与的多变量预测因素包括瘫痪（比值比 [OR]，2.11；95%CI，1.63-2.74）、抑郁（OR，1.99；95%CI，1.70-2.34）、充血性心力衰竭（OR，1.36；95%CI，1.17-1.58）和距离最近的 HBPC 提供 VA 设施的距离（OR，0.59；95%CI，10-30 英里以上 vs 5 英里以下为 0.50-0.70）。在使用工具变量分析控制选择偏倚后，HBPC 与因门诊护理敏感条件而住院的可能性显著降低相关（风险比，0.71；95%CI，0.57-0.89），1 年内住院概率绝对降低 5.8%。
家庭为基础的初级保健与老年糖尿病患者门诊护理敏感条件住院的可能性降低有关。在问责制护理模式中，HBPC 可能在管理患有多种慢性病的老年人方面发挥重要作用。
