Rodriguez Hector P, Friedberg Mark W, Vargas-Bustamante Arturo, Chen Xiao, Martinez Ana E, Roby Dylan H
Division of Health Policy and Management, School of Public Health, University of California, Berkeley, 50 University Hall, Room 245, Berkeley, CA, 94720, USA.
RAND Corporation, Boston, MA, USA.
BMC Health Serv Res. 2018 Nov 20;18(1):875. doi: 10.1186/s12913-018-3710-9.
To compare the impact of implementing team-based diabetes care management involving community health workers (CHWs) vs. medical assistants (MA) in community health centers (CHCs) on diabetes care processes, intermediate outcomes, and patients' experiences of chronic care.
Clinical and administrative data (n = 6111) and patient surveys (n = 698) pre-intervention and post-intervention. Surveys (n = 285) and key informant interviews (n = 48) of CHC staff assessed barriers and facilitators of implementation.
A three-arm cluster-randomized trial of CHC sites integrating MAs (n = 3) or CHWs (n = 3) for diabetes care management compared control CHC sites (n = 10). Difference-in-difference multivariate regression with exact matching of patients estimated intervention effects.
Patients in the CHW intervention arm had improved annual glycated hemoglobin testing (18.5%, p < 0.001), while patients in the MA intervention arm had improved low-density lipoprotein cholesterol control (8.4%, p < 0.05) and reported better chronic care experiences over time (β=7.5, p < 0.001). Except for chronic care experiences (p < 0.05) for patients in the MA intervention group, difference-in-difference estimates were not statistically significant because control group patients also improved over time. Some diabetes care processes improved significantly more for control group patients than intervention group patients. Key informant interviews revealed that immediate patient care issues sometimes crowded out diabetes care management activities, especially for MAs.
Diabetes care improved in CHCs integrating CHWs and MAs onto primary care teams, but the improvements were no different than improvements observed among matched control group patients. Greater improvement using CHW and MA team-based approaches may be possible if practice leaders minimize use of these personnel to cover shortages that often arise in busy primary care practices.
比较在社区卫生中心（CHC）实施由社区卫生工作者（CHW）或医疗助理（MA）参与的团队式糖尿病护理管理，对糖尿病护理流程、中间结果以及患者慢性病护理体验的影响。
干预前和干预后的临床及管理数据（n = 6111）以及患者调查（n = 698）。对社区卫生中心工作人员进行的调查（n = 285）和关键信息人访谈（n = 48）评估了实施的障碍和促进因素。
一项三臂整群随机试验，将整合了医疗助理（n = 3）或社区卫生工作者（n = 3）进行糖尿病护理管理的社区卫生中心站点与对照社区卫生中心站点（n = 10）进行比较。采用患者精确匹配的差分多元回归估计干预效果。
社区卫生工作者干预组的患者年度糖化血红蛋白检测得到改善（18.5%，p < 0.001），而医疗助理干预组的患者低密度脂蛋白胆固醇控制得到改善（8.4%，p < ），并且随着时间推移报告了更好的慢性病护理体验（β = 7.5，p < 0.001）。除了医疗助理干预组患者的慢性病护理体验（p < 0.05）外，差分估计无统计学意义，因为对照组患者也随着时间有所改善。一些糖尿病护理流程在对照组患者中改善得比干预组患者更显著。关键信息人访谈显示，即时的患者护理问题有时会排挤糖尿病护理管理活动，尤其是对医疗助理而言。
将社区卫生工作者和医疗助理纳入初级保健团队的社区卫生中心的糖尿病护理有所改善，但这些改善与匹配的对照组患者中观察到的改善并无差异。如果实践领导者尽量减少使用这些人员来弥补繁忙的初级保健实践中经常出现的短缺情况，那么采用基于社区卫生工作者和医疗助理团队的方法可能会有更大改善。
