Department of Pediatrics, University of Texas Medical School, Houston.
Pediatrix Medical Group, Dallas, Texas.
JAMA. 2014;312(24):2640-8. doi: 10.1001/jama.2014.16419.
Patient-centered medical homes have not been shown to reduce adverse outcomes or costs in adults or children with chronic illness.
To assess whether an enhanced medical home providing comprehensive care prevents serious illness (death, intensive care unit [ICU] admission, or hospital stay >7 days) and/or reduces costs among children with chronic illness.
DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial of high-risk children with chronic illness (≥3 emergency department visits, ≥2 hospitalizations, or ≥1 pediatric ICU admissions during previous year, and >50% estimated risk for hospitalization) treated at a high-risk clinic at the University of Texas, Houston, and randomized to comprehensive care (n = 105) or usual care (n = 96). Enrollment was between March 2011 and February 2013 (when predefined stopping rules for benefit were met) and outcome evaluations continued through August 31, 2013.
Comprehensive care included treatment from primary care clinicians and specialists in the same clinic with multiple features to promote prompt effective care. Usual care was provided locally in private offices or faculty-supervised clinics without modification.
Primary outcome: children with a serious illness (death, ICU admission, or hospital stay >7 days), costs (health system perspective). Secondary outcomes: individual serious illnesses, medical services, Medicaid payments, and medical school revenues and costs.
In an intent-to-treat analysis, comprehensive care decreased both the rate of children with a serious illness (10 per 100 child-years vs 22 for usual care; rate ratio [RR], 0.45 [95% CI, 0.28-0.73]), and total hospital and clinic costs ($16,523 vs $26,781 per child-year, respectively; cost ratio, 0.58 [95% CI, 0.38-0.88]). In analyses of net monetary benefit, the probability that comprehensive care was cost neutral or cost saving was 97%. Comprehensive care reduced (per 100 child-years) serious illnesses (16 vs 44 for usual care; RR, 0.33 [95% CI, 0.17-0.66]), emergency department visits (90 vs 190; RR, 0.48 [95% CI, 0.34-0.67]), hospitalizations (69 vs 131; RR, 0.51 [95% CI, 0.33-0.77]), pediatric ICU admissions (9 vs 26; RR, 0.35 [95% CI, 0.18-0.70]), and number of days in a hospital (276 vs 635; RR, 0.36 [95% CI, 0.19-0.67]). Medicaid payments were reduced by $6243 (95% CI, $1302-$11,678) per child-year. Medical school losses (costs minus revenues) increased by $6018 (95% CI, $5506-$6629) per child-year.
Among high-risk children with chronic illness, an enhanced medical home that provided comprehensive care to promote prompt effective care vs usual care reduced serious illnesses and costs. These findings from a single site of selected patients with a limited number of clinicians require study in larger, broader populations before conclusions about generalizability to other settings can be reached.
clinicaltrials.gov Identifier: NCT02128776.
重要提示：以患者为中心的医疗之家并没有被证明可以降低成人或慢性病患者的不良结局或成本。
目的：评估增强型医疗之家提供全面护理是否可以预防严重疾病（死亡、重症监护病房[ICU]入院或住院时间> 7 天）和/或降低慢性病儿童的成本。
设计、地点和参与者：这是一项在德克萨斯大学休斯顿分校高危诊所治疗的患有慢性疾病的高危儿童（≥3 次急诊就诊、≥2 次住院或≥1 次儿科 ICU 入院，以及> 50%的住院风险）的随机临床试验，随机分配到综合护理（n = 105）或常规护理（n = 96）。招募时间为 2011 年 3 月至 2013 年 2 月（当达到预先设定的获益停止标准时），并在 2013 年 8 月 31 日之前继续进行结果评估。
干预措施：全面护理包括由同一诊所的初级保健临床医生和专家提供的治疗，具有多种促进及时有效治疗的特征。常规护理在当地的私人办公室或由教师监督的诊所提供，没有进行修改。
主要结果和措施：主要结果：患有严重疾病（死亡、ICU 入院或住院时间> 7 天）的儿童，成本（医疗系统视角）。次要结果：个别严重疾病、医疗服务、医疗补助支付以及医学院的收入和成本。
结果：在意向治疗分析中，综合护理降低了儿童患有严重疾病的比率（每 100 个儿童年 10 例 vs 常规护理 22 例；比率比 [RR]，0.45 [95%置信区间，0.28-0.73]），以及总住院和诊所费用（分别为每儿童年 16523 美元和 26781 美元；成本比，0.58 [95%置信区间，0.38-0.88]）。在净货币收益分析中，综合护理成本中性或成本节约的概率为 97%。综合护理减少了（每 100 个儿童年）严重疾病（常规护理为 16 例，为 44 例；RR，0.33 [95%置信区间，0.17-0.66]）、急诊就诊（常规护理为 90 例，为 190 例；RR，0.48 [95%置信区间，0.34-0.67]）、住院（常规护理为 69 例，为 131 例；RR，0.51 [95%置信区间，0.33-0.77]）、儿科 ICU 入院（常规护理为 9 例，为 26 例；RR，0.35 [95%置信区间，0.18-0.70]）和住院天数（常规护理为 276 天，为 635 天；RR，0.36 [95%置信区间，0.19-0.67]）。医疗补助支付减少了 6243 美元（95%置信区间，1302 美元至 11678 美元）/儿童年。医学院损失（成本减去收入）增加了 6018 美元（95%置信区间，5506 美元至 6629 美元）/儿童年。
结论和相关性：在患有慢性疾病的高危儿童中，提供全面护理以促进及时有效治疗的增强型医疗之家与常规护理相比，可降低严重疾病和成本。这些来自选定患者数量有限的临床医生的单一地点研究结果需要在更大、更广泛的人群中进行研究，才能得出关于在其他环境中推广的结论。
试验注册：clinicaltrials.gov 标识符：NCT02128776。
