Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA.
Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA.
Healthc (Amst). 2020 Jun;8(2):100431. doi: 10.1016/j.hjdsi.2020.100431. Epub 2020 May 14.
At a population level, conversations between clinicians and seriously ill patients exploring patients' goals and values can drive high-value healthcare, improving patient outcomes and reducing spending.
We examined the impact of a quality improvement intervention to drive better communication on total medical expenses in a high-risk care management program. We present our analysis of secondary expense outcomes from a prospective implementation trial of the Serious Illness Care Program, which includes clinician training, coaching, tools, and system interventions. We included patients who died between January 2014 and September 2016 who were selected for serious illness conversations, using the "Surprise Question," as part of implementation of the program in fourteen primary care clinics.
We evaluated 124 patients and observed no differences in total medical expenses between intervention and comparison clinic patients. When comparing patients in intervention clinics who did and did not have conversations, we observed lower average monthly expenses over the last 6 ($6297 vs. $8,876, p = 0.0363) and 3 months ($7263 vs. $11,406, p = 0.0237) of life for patients who had conversations.
Possible savings observed in this study are similar in magnitude to previous studies in advance care planning and specialty palliative care but occur earlier in the disease course and in the context of documented conversations and a comprehensive, interprofessional case management program.
Programs designed to drive more, earlier, and better serious illness communication hold the potential to reduce costs.
Prospectively designed trial, non-randomized sample, analysis of secondary outcomes.
从人群层面来看，临床医生与重病患者进行探讨患者目标和价值观的对话，可以推动高价值医疗，改善患者预后并降低医疗支出。
我们考察了一项旨在改善沟通质量的质量改进干预措施对高风险护理管理项目中总医疗费用的影响。我们分析了一项严重疾病护理计划实施试验的次要费用结果，该计划包括临床医生培训、辅导、工具和系统干预。我们纳入了在 2014 年 1 月至 2016 年 9 月间死亡的患者，这些患者在十四家初级保健诊所实施该计划时，通过“意外问题”选择进行严重疾病对话。
我们评估了 124 名患者，发现干预组和对照组患者的总医疗费用没有差异。在比较干预组中进行和未进行对话的患者时，我们观察到最后 6 个月（6297 美元对 8876 美元，p = 0.0363）和 3 个月（7263 美元对 11406 美元，p = 0.0237）的月平均费用较低。
本研究中观察到的可能节省与之前在预先护理计划和专科姑息治疗中的研究相似，但发生在疾病过程的早期，并且有记录的对话和全面的跨专业病例管理计划为背景。
旨在促进更多、更早和更好的严重疾病沟通的计划有可能降低成本。
前瞻性设计的试验，非随机样本，次要结局分析。
