Ann Intern Med. 2016 Mar 1;164(5):323-30. doi: 10.7326/M14-2403. Epub 2016 Feb 2.
Patients with multiple chronic conditions are at high risk for potentially avoidable hospitalizations, which may be reduced by care coordination and self-management support. Medical assistants are an increasingly available resource for patient care in primary care practices.
To determine whether protocol-based care management delivered by medical assistants improves care in patients at high risk for future hospitalization in primary care.
Two-year cluster randomized clinical trial. (Current Controlled Trials: ISRCTN56104508).
115 primary care practices in Germany.
2076 patients with type 2 diabetes, chronic obstructive pulmonary disease, or chronic heart failure and a likelihood of hospitalization in the upper quartile of the population, as predicted by an analysis of insurance data.
Protocol-based care management, including structured assessment, action planning, and monitoring delivered by medical assistants, compared with usual care.
All-cause hospitalizations at 12 months (primary outcome) and quality-of-life scores (12-Item Short Form Health Survey [SF-12] and EuroQol instrument [EQ-5D]).
Included patients had an average of 4 co-occurring chronic conditions. All-cause hospitalizations did not differ between groups at 12 months (risk ratio [RR], 1.01 [95% CI, 0.87 to 1.18]) and 24 months (RR, 0.98 [CI, 0.85 to 1.12]). Quality of life (differences, 1.16 [CI, 0.24 to 2.08] on SF-12 physical component and 1.68 [CI, 0.60 to 2.77] on SF-12 mental component) and general health (difference on EQ-5D, 0.03 [CI, 0.00 to 0.05]) improved significantly at 24 months. Intervention costs totaled $10 per patient per month.
Small number of primary care practices and low intensity of intervention.
This low-intensity intervention did not reduce all-cause hospitalizations but showed positive effects on quality of life at reasonable costs in high-risk multimorbid patients.
AOK Baden-Württemberg and AOK Bundesverband.
患有多种慢性病的患者存在潜在可避免住院的高风险，通过护理协调和自我管理支持可能会降低这种风险。医疗助理是初级保健实践中患者护理的日益可用资源。
确定由医疗助理提供的基于协议的护理管理是否可以改善高风险患者未来在初级保健中的护理。
为期两年的群组随机临床试验。（当前对照试验：ISRCTN56104508）。
德国 115 个初级保健诊所。
2076 名患有 2 型糖尿病、慢性阻塞性肺疾病或慢性心力衰竭的患者，以及根据保险数据分析预测的住院可能性处于人口上四分位数的患者。
基于协议的护理管理，包括由医疗助理提供的结构化评估、行动计划和监测，与常规护理相比。
12 个月时的全因住院率（主要结局）和生活质量评分（12 项短表单健康调查 [SF-12] 和欧洲五维健康量表 [EQ-5D]）。
纳入的患者平均有 4 种共病。12 个月和 24 个月时，全因住院率在两组之间没有差异（风险比 [RR]，1.01 [95%CI，0.87 至 1.18]）和 24 个月（RR，0.98 [CI，0.85 至 1.12]）。生活质量（差异，SF-12 生理成分上为 1.16 [CI，0.24 至 2.08]，SF-12 心理成分上为 1.68 [CI，0.60 至 2.77]）和一般健康（EQ-5D 上的差异，0.03 [CI，0.00 至 0.05]）在 24 个月时显著改善。干预成本为每位患者每月 10 美元。
初级保健实践数量少，干预强度低。
这种低强度干预措施并未降低全因住院率，但在高风险多种慢性病患者中以合理的成本显示出对生活质量的积极影响。
AOK Baden-Württemberg 和 AOK Bundesverband。
