Denver Health and Hospital Association, Denver, CO, USA.
Denver Health and Hospital Association, Denver, CO, USA; University of Colorado, School of Medicine, Aurora, CO, USA.
Healthc (Amst). 2018 Dec;6(4):253-258. doi: 10.1016/j.hjdsi.2017.08.004. Epub 2017 Aug 25.
Interventions designed to improve care and reduce costs for patients with the highest rates of hospital utilization (super-utilizers) continue to proliferate, despite conflicting evidence of cost savings.
We evaluated a practice transformation intervention that implemented team-based care and risk-stratification to match specific primary care resources based on need. This included an intensive outpatient clinic for super-utilizers. We used multivariate regression and a difference-in-differences approach to compare changes in mortality, utilization, and charges between the intervention group and a historical control. Sensitivity analyses tested the robustness of findings and revealed the inherent challenges associated with quasi-experimental designs.
Observed charges for the intervention group were significantly lower than expected charges as derived by the trend of the historical control (p<0.04) resulting in total charge avoidance of approximately $26 million. While inpatient admissions were significantly higher (p<0.01), charges associated with total inpatient (p=0.01), intensive-care unit (p<0.05, not robust to sensitivity analyses), and surgery (p<0.01) were significantly lower than expected in the intervention group. One year mortality was significantly less in the intervention group (12.6% vs 11.5%, p<0.01).
The use of tailored services, including a dedicated intensive outpatient clinic, for super-utilizers within a larger primary care practice transformation reduced mortality and provided significant savings, even while total hospitalizations increased. These savings were achieved through a reduction in the intensity of inpatient services. The unexpected finding of a reduction in ICU charges deserves further exploration.
These findings suggest that intensity of inpatient service, and not merely volume of services, should be considered a focus for future intervention design and evaluated as an outcome.
Level III (Quasi-Experimental Design).
尽管有节约成本的证据相互矛盾，但旨在提高医疗利用率最高的患者（超级使用者）的护理质量并降低成本的干预措施仍在不断增加。
我们评估了一种实践转型干预措施，该措施实施了基于团队的护理和风险分层，根据需要为特定的初级保健资源匹配特定的资源。这包括为超级使用者设立一个强化门诊诊所。我们使用多元回归和差异中的差异方法来比较干预组与历史对照组在死亡率、利用率和费用方面的变化。敏感性分析测试了研究结果的稳健性，并揭示了与准实验设计相关的固有挑战。
与历史对照组的趋势相比，干预组的观察费用明显低于预期费用（p<0.04），从而避免了约 2600 万美元的总费用。虽然住院人数明显增加（p<0.01），但干预组的总住院（p=0.01）、重症监护病房（p<0.05，敏感性分析不稳健）和手术（p<0.01）的费用明显低于预期。干预组的一年死亡率明显较低（12.6%比 11.5%，p<0.01）。
在更大的初级保健实践转型中，为超级使用者提供定制服务，包括专门的强化门诊诊所，可以降低死亡率并节省大量费用，即使住院人数增加。这些节省是通过减少住院服务的强度来实现的。意外发现 ICU 费用减少值得进一步探讨。
这些发现表明，应该将住院服务的强度而不仅仅是服务量作为未来干预设计的重点，并将其作为结果进行评估。
三级（准实验设计）。
