Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Center for Population Health Sciences, Hanoi University of Public Health, Hanoi, Viet Nam.
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA; The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA; Johns Hopkins HealthCareLLC, Glen Burnie, MD, USA.
J Diabetes Complications. 2019 Jun;33(6):445-450. doi: 10.1016/j.jdiacomp.2018.12.011. Epub 2019 Jan 22.
To assess whether an all-condition case management program can improve health care utilization and clinical outcomes in patients with diabetes.
1342 patients with diabetes were enrolled in the Johns Hopkins Community Health Partnership (J-CHiP) Case Management program for high-risk patients with any chronic disease. We categorized participants into two intervention exposure categories based on the number of contacts with case manager (CM) and community health worker (CHW) per month: low contact (≤1 contact/month), and high contact (>1 contacts/month). The primary outcomes were rates of emergency department (ED) visits, hospitalizations, and 30-day hospital readmissions.
In analyses adjusted for age, sex, race, risk score, and baseline health utilization rate, Medicaid participants in the high contact group had 42% (rate ratio (RR): 1.42; 95% CI: 1.08-1.86) and 64% (RR: 1.64; 95% CI: 1.08-2.48) higher risks for hospital admission and readmission, respectively, than the low contact group. Similar increases were seen in the Medicare participants with 20% (RR: 1.20; 95% 1.02-1.42) and 42% (RR:1.42; 95% 1.09-1.84) higher risks for admission and readmission, respectively. The associations were not statistically significant for ED visits. Subsidiary analysis of a subset with HbA1c available (n = 545) revealed a statistically significant decrease in HbA1c among Medicare participants (mean (SD): -0.17% (1.50%)), with a larger decrease in the high contact group (mean (SD): -0.23% (1.59%)).
In an all-condition case management program for high-risk patients, the higher intensity of contacts with CHW and CM was not associated with a reduced health care utilization in adults with diabetes.
评估全病种病例管理方案能否改善患有糖尿病的患者的医疗保健利用度和临床结局。
共纳入 1342 名患有糖尿病的患者，他们参加了约翰霍普金斯社区健康伙伴关系（J-CHiP）的高危慢性病患者病例管理项目。我们根据每月与病例经理（CM）和社区卫生工作者（CHW）的接触次数将参与者分为两个干预接触类别：低接触（≤1 次/月）和高接触（>1 次/月）。主要结局是急诊就诊率、住院率和 30 天内再次住院率。
在调整了年龄、性别、种族、风险评分和基线医疗保健利用率后，高接触组中的医疗补助参与者的住院和再入院风险分别高出低接触组 42%（RR：1.42；95%CI：1.08-1.86）和 64%（RR：1.64；95%CI：1.08-2.48）。在医疗保险参与者中也观察到类似的增加，住院和再入院的风险分别高出低接触组 20%（RR：1.20；95%CI：1.02-1.42）和 42%（RR：1.42；95%CI：1.09-1.84）。但急诊就诊率的相关性没有统计学意义。对 HbA1c 可用的亚组（n=545）的次要分析显示，医疗保险参与者的 HbA1c 显著降低（平均（标准差）：-0.17%（1.50%）），高接触组的降幅更大（平均（标准差）：-0.23%（1.59%））。
在针对高危患者的全病种病例管理方案中，CHW 和 CM 的接触强度增加与糖尿病成人的医疗保健利用度降低无关。
