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复杂多病共存患者的病例管理:基层医疗与医院医疗之间协调干预措施的制定与验证

Case Management for Patients with Complex Multimorbidity: Development and Validation of a Coordinated Intervention between Primary and Hospital Care.

作者信息

Tortajada Salvador, Giménez-Campos María Soledad, Villar-López Julia, Faubel-Cava Raquel, Donat-Castelló Lucas, Valdivieso-Martínez Bernardo, Soriano-Melchor Elisa, Bahamontes-Mulió Amparo, García-Gómez Juan M

机构信息

Instituto de Investigación Sanitaria La Fe, ES.

Hospital Universitario y Politécnico La Fe, ES.

出版信息

Int J Integr Care. 2017 Jun 20;17(2):4. doi: 10.5334/ijic.2493.

Abstract

In the past few years, healthcare systems have been facing a growing demand related to the high prevalence of chronic diseases. Case management programs have emerged as an integrated care approach for the management of chronic disease. Nevertheless, there is little scientific evidence on the impact of using a case management program for patients with complex multimorbidity regarding hospital resource utilisation. We evaluated an integrated case management intervention set up by community-based care at outpatient clinics with nurse case managers from a telemedicine unit. The hypothesis to be tested was whether improved continuity of care resulting from the integration of community-based and hospital services reduced the use of hospital resources amongst patients with complex multimorbidity. A retrospective cohort study was performed using a sample of 714 adult patients admitted to the program between January 2012 and January 2015. We found a significant decrease in the number of emergency room visits, unplanned hospitalizations, and length of stay, and an expected increase in the home care hospital-based episodes. These results support the hypothesis that case management interventions can reduce the use of unplanned hospital admissions when applied to patients with complex multimorbidity.

摘要

在过去几年中,医疗保健系统一直面临着与慢性病高患病率相关的日益增长的需求。病例管理计划已成为一种用于慢性病管理的综合护理方法。然而,关于针对患有复杂多种慢性病的患者使用病例管理计划对医院资源利用的影响,几乎没有科学证据。我们评估了由社区门诊护理与远程医疗单位的护士病例经理设立的综合病例管理干预措施。要检验的假设是,基于社区和医院服务整合所带来的护理连续性改善是否减少了患有复杂多种慢性病患者对医院资源的使用。我们进行了一项回顾性队列研究,样本为2012年1月至2015年1月期间纳入该计划的714名成年患者。我们发现急诊就诊次数、非计划性住院次数和住院时间显著减少,且基于家庭护理的医院护理次数预期增加。这些结果支持了这样的假设,即病例管理干预措施应用于患有复杂多种慢性病的患者时,可以减少非计划性住院的使用。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/8ffb/5624062/00195377ac1f/ijic-17-2-2493-g1.jpg

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