Center for Applied Health Services Research, Ochsner Clinic Foundation, New Orleans, LA, USA.
Ochsner Clinical School, University of Queensland, New Orleans, LA, USA.
J Gen Intern Med. 2018 Nov;33(11):1921-1927. doi: 10.1007/s11606-018-4616-2. Epub 2018 Aug 3.
U.S. health systems, incentivized by financial penalties, are designing programs such as case management to reduce service utilization among high-cost, high-need populations. The major challenge is identifying patients for whom targeted programs are most effective for achieving desired outcomes.
To evaluate a health system's outpatient complex case management (OPCM) for Medicare beneficiaries for patients overall and for high-risk patients using system-tailored taxonomy, and examine whether OPCM lowers service utilization and healthcare costs.
Retrospective case-control study using Medicare data collected between 2012 and 2016 for Ochsner Health System.
Super-utilizers defined as Medicare patients with at least two hospital/ED encounters within 180 days of the index date including the index event.
Outpatient complex case management.
Propensity score-adjusted multivariable logistic regression analysis was conducted for primary outcomes (90-day hospital readmission; 90-day ED re-visit). A difference-in-difference analysis was conducted to examine changes in per membership per month (PMPM) costs based on OPCM exposure.
Among 18,882 patients, 1197 (6.3%) were identified as "high-risk" and 470 (2.5%) were OPCM participants with median enrollment of 49 days. High-risk OPCM cases compared to high-risk controls had lower odds of 90-day hospital readmissions (0.81 [0.40-1.61], non-significant) and lower odds of 90-day ED re-visits (0.50 [0.32-0.79]). Non-high-risk OPCM cases compared to non-high-risk controls had lower odds of 90-day hospital readmissions (0.20 [0.11-0.36]) and 90-day ED re-visits (0.66 [0.47-0.94]). Among OPCM cases, high-risk patients compared to non-high-risk patients had greater odds of 90-day hospital readmissions (4.44 [1.87-10.54]); however, there was no difference in 90-day ED re-visits (0.99 [0.58-1.68]). Overall, OPCM cases had lower total cost of care compared to controls (PMPM mean [SD]: - $1037.71 [188.18]).
Use of risk stratification taxonomy for super-utilizers can identify patients most likely to benefit from case management. Future studies must further examine which OPCM components drive improvements in select outcome for specific populations.
美国医疗体系受到经济处罚的激励，正在设计病例管理等项目，以降低高成本、高需求人群的服务利用率。主要挑战是确定针对哪些患者实施目标计划可以最有效地实现预期结果。
评估医疗系统针对医疗保险受益人的门诊复杂病例管理（OPCM），总体上针对患者，以及使用系统定制分类法针对高风险患者，同时检查 OPCM 是否降低服务利用率和医疗保健成本。
使用 2012 年至 2016 年期间 Ochsner 健康系统收集的医疗保险数据进行回顾性病例对照研究。
超级用户定义为在索引日期后 180 天内至少有两次医院/急诊就诊的医疗保险患者，包括索引事件。
门诊复杂病例管理。
采用倾向评分调整多变量逻辑回归分析主要结局（90 天内再次住院；90 天内再次急诊就诊）。基于 OPCM 暴露情况，采用差异分析法分析每个会员每月（PMPM）成本的变化。
在 18882 名患者中，有 1197 名（6.3%）被确定为“高风险”，有 470 名（2.5%）是 OPCM 参与者，中位入组时间为 49 天。与高风险对照组相比，高风险 OPCM 病例 90 天内再次住院的可能性更低（0.81 [0.40-1.61]，无统计学意义），90 天内再次急诊就诊的可能性也更低（0.50 [0.32-0.79]）。与非高风险对照组相比，非高风险 OPCM 病例 90 天内再次住院的可能性更低（0.20 [0.11-0.36]），90 天内再次急诊就诊的可能性也更低（0.66 [0.47-0.94]）。在 OPCM 病例中，与非高风险患者相比，高风险患者 90 天内再次住院的可能性更高（4.44 [1.87-10.54]）；然而，90 天内再次急诊就诊的可能性没有差异（0.99 [0.58-1.68]）。总体而言，与对照组相比，OPCM 病例的总医疗费用更低（PMPM 平均值[标准差]：-1037.71 美元[188.18]）。
使用超级用户风险分层分类法可以识别最有可能从病例管理中受益的患者。未来的研究必须进一步研究哪些 OPCM 组件可以为特定人群的特定结果带来改善。
