高医疗复杂性风险儿童的医疗之家的获益的试验后可持续性和扩展性
Post-Trial Sustainability and Scalability of the Benefits of a Medical Home for High-Risk Children with Medical Complexity.
机构信息
Department of Pediatrics. McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX; Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, TX.
Department of Pediatrics. McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX; Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, TX.
出版信息
J Pediatr. 2019 Mar;206:232-239.e3. doi: 10.1016/j.jpeds.2018.10.035. Epub 2018 Dec 4.
OBJECTIVE
To assess the sustainability of the benefits relative to usual care of a medical home providing comprehensive care for high-risk children with medical complexity (≥2 hospitalizations or ≥1 pediatric intensive care unit [PICU] admission in the year before enrollment) after we made comprehensive care our standard practice and expanded the program.
STUDY DESIGN
We conducted pre-post comparisons of the rate of children with serious illness (death, PICU admission, or >7-day hospitalization) and health-system costs observed after program expansion (March 2014-June 2015) to those during the clinical trial (March 2011-August 2013) for each of the trial's treatment groups (usual care, n = 96, and comprehensive care, n = 105; primary analyses), and among all children given comprehensive care (n = 233, including trial usual care children who transitioned to comprehensive care post-trial and newly enrolled medically complex children, and n = 105; secondary analyses). We also analyzed the findings for the trial patients as a 2-phase stepped-wedge study.
RESULTS
In intent-to-treat analyses, rates of children with serious illness and costs were reduced or unchanged post-trial vs trial for the trial's usual care group (rate ratio [RR], 0.36; 95% CI, 0.20-0.64; cost ratio [CR], 0.68; 95% CI, 0.28-1.68), the trial's comprehensive care group (RR, 0.74; 95% CI, 0.39-1.41; CR, 0.67; 95% CI, 0.51-0.89), and among all children given comprehensive care (RR, 0.97; 95% CI, 0.61-1.52; CR, 0.75; 95% CI, 0.61-0.93). Conservative stepped-wedge analyses identified overall benefits with comprehensive care across both study periods (RR, 0.46; 95% CI, 0.30-0.72; CR, 0.64; 95% CI, 0.43-0.99).
CONCLUSIONS
Major benefits of comprehensive care did not diminish with post-trial program expansion.
目的
在将全面医疗照护作为标准实践并扩大项目后，评估为高风险合并医疗复杂性的儿童（在入组前 1 年中住院 2 次或以上或入住儿科重症监护病房 1 次或以上）提供全面医疗照护的医疗之家的益处相对于常规护理的可持续性。
研究设计
我们对方案扩大后（2014 年 3 月至 2015 年 6 月）观察到的严重疾病（死亡、入住儿科重症监护病房或住院 7 天以上）发生率和医疗系统成本（每组的试验治疗组（常规护理，n = 96，综合护理，n = 105；主要分析）和所有接受综合护理的儿童（n = 233，包括试验常规护理后转为综合护理的儿童和新入组的合并医疗复杂的儿童，n = 105；次要分析）与试验期间的发生率和成本进行了前后比较。我们还对试验患者进行了两阶段阶梯式楔形研究分析。
结果
意向治疗分析中，与试验相比，试验常规护理组（率比[RR]，0.36；95%置信区间[CI]，0.20-0.64；成本比[CR]，0.68；95%CI，0.28-1.68）、试验综合护理组（RR，0.74；95%CI，0.39-1.41；CR，0.67；95%CI，0.51-0.89）和所有接受综合护理的儿童（RR，0.97；95%CI，0.61-1.52；CR，0.75；95%CI，0.61-0.93）在试验后，严重疾病和成本的发生率降低或不变。保守的阶梯式楔形分析在整个研究期间均确定了综合护理的总体益处（RR，0.46；95%CI，0.30-0.72；CR，0.64；95%CI，0.43-0.99）。
结论
在试验后方案扩大后，全面医疗照护的主要益处并未减弱。
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