RTI-University of North Carolina Evidence-Based Practice Center, Research Triangle Park, NC, USA.
RTI International, Research Triangle Park, NC, USA.
J Gen Intern Med. 2023 Jan;38(1):185-194. doi: 10.1007/s11606-022-07809-6. Epub 2022 Oct 11.
Chronic disease patients who are the greatest users of healthcare services are often referred to as high-need, high-cost (HNHC). Payers, providers, and policymakers in the United States are interested in identifying interventions that can modify or reduce preventable healthcare use among these patients, without adversely impacting their quality of care and health. We systematically reviewed the evidence on the effectiveness of complex interventions designed to change the healthcare of HNHC patients, modifying cost and utilization, as well as clinical/functional, and social risk factor outcomes.
We searched 8 electronic databases (January 2000 to March 2021) and selected non-profit organization and government agency websites for randomized controlled trials and observational studies with comparison groups that targeted HNHC patients. Two investigators independently screened each study and abstracted data into structured forms. Study quality was assessed using standard risk of bias tools. Random-effects meta-analysis was conducted for outcomes reported by at least 3 comparable samples.
Forty studies met our inclusion criteria. Interventions were heterogenous and classified into 7 categories, reflecting the predominant service location/modality (home, primary care, ambulatory intensive caring unit [aICU], emergency department [ED], community, telephonic/mail, and system-level). Home-, primary care-, and ED-based interventions resulted in reductions in high-cost healthcare services (ED and hospital use). ED-based interventions also resulted in greater use of primary care. Primary care- and ED-based interventions reduced costs. System-level transformation interventions did not reduce costs.
We found limited evidence of intervention effectiveness in relation to cost and use, and additional evidence is needed to strengthen our confidence in the findings. Few studies reported patient clinical/functional or social risk factor outcomes (e.g., homelessness) or sufficient details for determining why individual interventions work, for whom, and when. Future evaluations could provide additional insights, by including intermediate process outcomes and patients' experiences, in assessing the impact of these complex interventions.
CRD42020161179.
慢性病患者是医疗服务的最大使用者，通常被称为高需求、高成本（HNHC）患者。美国的支付方、提供者和政策制定者都有兴趣确定可以改变这些患者可避免的医疗保健使用的干预措施，而不会对其护理质量和健康产生不利影响。我们系统地回顾了关于旨在改变 HNHC 患者医疗保健、改变成本和利用以及临床/功能和社会风险因素结果的复杂干预措施的有效性的证据。
我们搜索了 8 个电子数据库（2000 年 1 月至 2021 年 3 月），并为针对 HNHC 患者的随机对照试验和具有对照组的观察性研究选择了非营利组织和政府机构网站。两名调查员独立筛选每项研究并将数据摘要到结构化表格中。使用标准偏倚风险工具评估研究质量。对至少有 3 个可比样本报告的结果进行了随机效应荟萃分析。
40 项研究符合我们的纳入标准。干预措施具有异质性，并分为 7 类，反映了主要的服务地点/模式（家庭、初级保健、门诊强化护理病房[aICU]、急诊部[ED]、社区、电话/邮件和系统级）。基于家庭、初级保健和 ED 的干预措施导致高成本医疗服务（ED 和医院使用）减少。ED 为基础的干预措施也导致更多地使用初级保健。初级保健和 ED 为基础的干预措施降低了成本。系统级转型干预措施没有降低成本。
我们发现干预措施在成本和使用方面的有效性证据有限，需要更多的证据来增强我们对这些发现的信心。很少有研究报告患者的临床/功能或社会风险因素结果（例如，无家可归）或足够的细节来确定为什么个别干预措施有效、对谁有效和何时有效。未来的评估可以通过在评估这些复杂干预措施的影响时纳入中间过程结果和患者的经验，提供更多的见解。
PROSPERO 注册号：CRD42020161179。
