Simon Tamara D, Whitlock Kathryn B, Haaland Wren, Wright Davene R, Zhou Chuan, Neff John, Howard Waylon, Cartin Brian, Mangione-Smith Rita
Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and
Centers for Clinical and Translational Research and.
Pediatrics. 2017 Dec;140(6). doi: 10.1542/peds.2017-1641.
To assess whether children with medical complexity (CMC) exposed to a hospital-based comprehensive case management service (CCMS) experience improved health care quality, improved functional status, reduced hospital-based utilization, and/or reduced overall health care costs.
Eligible CMC at Seattle Children's Hospital were enrolled in a cluster randomized controlled trial between December 1, 2010, and September 29, 2014. Participating primary care providers (PCPs) were randomly assigned, and CMC either had access to an outpatient hospital-based CCMS or usual care directed by their PCP. The CCMS included visits to a multidisciplinary clinic ≥ every 6 months for 1.5 years, an individualized shared care plan, and access to CCMS providers. Differences between control and intervention groups in change from baseline to 12 months and baseline to 18 months (difference of differences) were tested.
Two hundred PCPs caring for 331 CMC were randomly assigned. Intervention group ( = 181) parents reported more improvement in the Consumer Assessment of Healthcare Providers and Systems version 4.0 Child Health Plan Survey global health care quality ratings than control group parents (6.7 [95% confidence interval (CI): 3.5-9.8] vs 1.3 [95% CI: 1.9-4.6] at 12 months). We did not detect significant differences in child functional status and most hospital-based utilization between groups. The difference in change of overall health care costs was higher in the intervention group (+$8233 [95% CI: $1701-$16 937]) at 18 months). CCMS clinic costs averaged $3847 per child-year.
Access to a CCMS generally improved health care quality, but was not associated with changes in child functional status or hospital-based utilization, and increased overall health care costs among CMC.
评估患有复杂疾病的儿童（CMC）接受以医院为基础的综合病例管理服务（CCMS）后，其医疗质量是否得到改善、功能状态是否得到改善、基于医院的利用率是否降低以及/或者总体医疗费用是否降低。
2010年12月1日至2014年9月29日期间，西雅图儿童医院符合条件的CMC被纳入一项整群随机对照试验。参与的初级保健提供者（PCP）被随机分配，CMC要么可以获得以医院门诊为基础的CCMS，要么接受由其PCP指导的常规护理。CCMS包括每6个月至少到多学科诊所就诊一次，为期1.5年，制定个性化的共享护理计划，并可联系CCMS提供者。对对照组和干预组从基线到12个月以及从基线到18个月的变化差异（差异的差异）进行了测试。
随机分配了200名照顾331名CMC的PCP。干预组（=181）的家长报告称，在医疗服务提供者和系统消费者评估第4.0版儿童健康计划调查中，全球医疗质量评分的改善程度高于对照组家长（12个月时为6.7[95%置信区间（CI）：3.5 - 9.8]，而对照组为1.3[95%CI：1.9 - 4.6]）。我们未发现两组之间儿童功能状态和大多数基于医院的利用率存在显著差异。18个月时，干预组总体医疗费用变化差异更高（+$8233[95%CI：$1701 - $16937]）。CCMS诊所的费用平均为每个儿童每年3847美元。
获得CCMS通常会改善医疗质量，但与儿童功能状态或基于医院的利用率变化无关，并且会增加CMC的总体医疗费用。
