Division of General Internal Medicine, Department of Medicine, University of California at San Francisco, San Francisco, California, USA.
Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 94612, Oakland, CA, USA.
J Gen Intern Med. 2018 Sep;33(9):1454-1460. doi: 10.1007/s11606-018-4488-5. Epub 2018 May 24.
A large and increasing proportion of health care costs are spent caring for a small segment of medically and socially complex patients. To date, it has been difficult to identify which patients are best served by intensive care management.
To characterize factors that best identify which complex patients are most suited for intensive care management.
We conducted a mixed-methods study involving 35 care managers (CMs; 10 licensed social workers and 25 registered nurses) working in intensive care management programs within Kaiser Permanente Northern California (KPNC) outpatient medical centers. We asked CMs to review a randomly selected list of up to 50 patients referred to them in the prior year and to categorize each patient as either (1) "good candidates" for care management, (2) "not needing" intensive care management, or (3) "needing more" than traditional care management could provide. We then conducted semi-structured interviews to understand how CMs separated patients into these three groups.
CMs assigned 1178 patients into the 3 referral categories. Less than two thirds (62%, n = 736) of referred patients were considered good candidates, with 18% (n = 216) categorized as not needing care management and 19% (n = 226) as needing more. Compared to the other two categories, good candidates were older (76.2 years vs. 73.2 for not needing and 69.8 for needing more, p < 0.001), prescribed more medications (p = 0.02) and had more prior year outpatient visits (p = 0.04), while the number of prior year hospital and emergency room admissions were greater than not needing but less than needing more (p < 0.001). A logistic regression model using available electronic record data predicted good candidate designation with a c statistic of 0.75. Several qualitative themes emerged that helped define appropriateness for referral, including availability of social support, patient motivation, non-medical transitions, recent trajectory of medical condition, and psychiatric or substance use issues.
Many apparently complex patients are not good candidates for intensive care management. Current electronic medical records do not capture several of the most salient characteristics that determine appropriateness for care management. Our findings suggest that systematic collection of social support, patient motivation, and recent non-medically related life change information may help identify which complex patients are most likely to benefit from care management.
大量且不断增加的医疗保健费用用于照顾一小部分医学上和社会上都很复杂的患者。迄今为止，很难确定哪些患者最适合接受重症监护管理。
确定哪些复杂患者最适合重症监护管理。
我们进行了一项混合方法研究，研究对象为 35 名从事重症监护管理项目的护理经理（CM；10 名持照社会工作者和 25 名注册护士），他们在 Kaiser Permanente Northern California（KPNC）门诊医疗中心工作。我们要求 CMs 查看他们在前一年中随机挑选的最多 50 名患者的名单，并将每位患者归类为以下三类之一：（1）“适合”接受护理管理，（2）“不需要”重症监护管理，或（3）“需要”比传统护理管理更多的护理管理。然后，我们进行了半结构化访谈，以了解 CMs 如何将患者分为这三类。
CMs 将 1178 名患者分配到这 3 个转介类别。不到三分之二（62%，n=736）的转介患者被认为是合适的候选者，18%（n=216）被归类为不需要护理管理，19%（n=226）需要更多护理管理。与其他两类相比，合适的候选者年龄更大（76.2 岁，而不需要的为 73.2 岁，需要更多的为 69.8 岁，p<0.001），服用的药物更多（p=0.02），前一年的门诊就诊次数更多（p=0.04），而前一年的住院和急诊就诊次数则多于不需要但少于需要更多（p<0.001）。使用现有电子病历数据的逻辑回归模型预测合适候选者的指定，其 c 统计量为 0.75。出现了几个定性主题，有助于确定转介的适宜性，包括社会支持的可用性、患者的动机、非医疗过渡、近期病情轨迹以及精神或药物使用问题。
许多看似复杂的患者并不适合接受重症监护管理。当前的电子病历并未捕获确定护理管理适宜性的几个最显著特征。我们的研究结果表明，系统收集社会支持、患者动机和最近与医疗无关的生活变化信息，可能有助于确定哪些复杂患者最有可能从护理管理中受益。
