Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California2Division of General Medical Disciplines, Stanford University, Stanford, California3Medical Services, VA Palo Alto Health Care System, Palo Alto, California.
Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California4Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California.
JAMA Intern Med. 2017 Feb 1;177(2):166-175. doi: 10.1001/jamainternmed.2016.8021.
Many organizations are adopting intensive outpatient care programs for high-need patients, yet little is known about their effectiveness in integrated systems with established patient-centered medical homes.
To evaluate how augmenting the Veterans Affairs (VA) medical home (Patient Aligned Care Teams [PACT]) with an Intensive Management program (ImPACT) influences high-need patients' costs, health care utilization, and experience.
DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial at a single VA facility. Among 583 eligible high-need outpatients whose health care costs or hospitalization risk were in the top 5% for the facility, 150 were randomly selected for ImPACT; the remaining 433 received standard PACT care.
The ImPACT multidisciplinary team addressed health care needs and quality of life through comprehensive patient assessments, intensive case management, care coordination, and social and recreational services.
Primary difference-in-difference analyses examined changes in health care costs and acute and extended care utilization over a 16-month baseline and 17-month follow-up period. Secondary analyses estimated the intervention's effect on ImPACT participants (using randomization as an instrument) and for patients with key sociodemographic and clinical characteristics. ImPACT participants' satisfaction and activation levels were assessed using responses to quality improvement surveys administered at baseline and 6 months.
Of 140 patients assigned to ImPACT, 96 (69%) engaged in the program (mean [SD] age, 68.3 [14.2] years; 89 [93%] male; mean [SD] number of chronic conditions, 10 [4]; 62 [65%] had a mental health diagnosis; 21 [22%] had a history of homelessness). After accounting for program costs, adjusted person-level monthly health care expenditures decreased similarly for ImPACT and PACT patients (difference-in-difference [SE] -$101 [$623]), as did acute and extended care utilization rates. Among respondents to the ImPACT follow-up survey (n = 54 [56% response rate]), 52 (96%) reported that they would recommend the program to others, and pre-post analyses revealed modest increases in satisfaction with VA care (mean [SD] increased from 2.90 [0.72] to 3.16 [0.60]; P = .04) and communication (mean [SD] increased from 2.99 [0.74] to 3.18 [0.60]; P = .03).
Intensive outpatient care for high-need patients did not reduce acute care utilization or costs compared with standard VA care, although there were positive effects on experience among patients who participated. Implementing intensive outpatient care programs in integrated settings with well-established medical homes may not prevent hospitalizations or achieve substantial cost savings.
clinicaltrials.gov Identifier: NCT02932228.
重要性：许多组织正在为高需求患者采用强化门诊护理计划，但在具有既定以患者为中心的医疗之家的综合系统中，其效果知之甚少。
目的：评估在退伍军人事务部（VA）医疗之家（患者一致护理团队[PACT]）中增加强化管理计划（ImPACT）如何影响高需求患者的成本、医疗保健利用和体验。
设计、地点和参与者：在单一 VA 设施进行的随机临床试验。在设施的医疗费用或住院风险处于前 5%的 583 名合格高需求门诊患者中，随机选择 150 名患者参加 ImPACT；其余 433 名患者接受标准 PACT 护理。
干预措施：ImPACT 多学科团队通过全面的患者评估、强化病例管理、护理协调以及社会和娱乐服务来满足患者的医疗需求和提高生活质量。
主要结果和措施：主要差异差异分析研究了在 16 个月的基线和 17 个月的随访期间，医疗保健成本和急性及扩展护理利用的变化。次要分析估计了干预措施对 ImPACT 参与者（使用随机化作为工具）以及具有关键社会人口统计学和临床特征的患者的影响。在基线和 6 个月时进行的质量改进调查中，使用响应来评估 ImPACT 参与者的满意度和激活水平。
结果：在被分配到 ImPACT 的 140 名患者中，有 96 名（69%）参与了该计划（平均[标准差]年龄，68.3[14.2]岁；89[93%]男性；平均[标准差]慢性疾病数量，10[4]；62[65%]有心理健康诊断；21[22%]有流浪史）。在考虑到计划成本后，ImPACT 和 PACT 患者的人均月度医疗保健支出同样减少（差异差异[SE]-$101[623]），急性和扩展护理利用率也同样下降。在对 ImPACT 随访调查做出回应的受访者中（n=54[56%的回应率]），有 52 名（96%）表示他们会向他人推荐该计划，且前后分析显示他们对 VA 护理的满意度有适度提高（平均[标准差]从 2.90[0.72]增加到 3.16[0.60]；P=0.04）和沟通（平均[标准差]从 2.99[0.74]增加到 3.18[0.60]；P=0.03）。
结论和相关性：与标准 VA 护理相比，强化门诊护理并未降低高需求患者的急性护理利用率或成本，但参与的患者在体验方面有积极影响。在具有既定以患者为中心的医疗之家的综合环境中实施强化门诊护理计划可能无法预防住院或实现大量成本节约。
试验注册：clinicaltrials.gov 标识符：NCT02932228。
