Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA; VA Puget Sound Health Care System, Center of Innovation for Veteran-Centered and Value- Driven Care, Seattle, WA, USA.
Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA; VA Puget Sound Health Care System, Center of Innovation for Veteran-Centered and Value- Driven Care, Seattle, WA, USA; Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA.
Healthc (Amst). 2023 Jun;11(2):100677. doi: 10.1016/j.hjdsi.2023.100677. Epub 2023 Feb 8.
Primary care intensive management programs utilize interdisciplinary care teams to comprehensively meet the complex care needs of patients at high risk for hospitalization. The mixed evidence on the effectiveness of these programs focuses on average treatment effects that may mask heterogeneous treatment effects (HTEs) among subgroups of patients. We test for HTEs by patients' demographic, economic, and social characteristics.
Retrospective analysis of a VA randomized quality improvement trial. 3995 primary care patients at high risk for hospitalization were randomized to primary care intensive management (n = 1761) or usual primary care (n = 1731). We estimated HTEs on ED and hospital utilization one year after randomization using model-based recursive partitioning and a pre-versus post-with control group framework. Splitting variables included administratively collected demographic characteristics, travel distance, copay exemption, risk score for future hospitalizations, history of hospital discharge against medical advice, homelessness, and multiple residence ZIP codes.
There were no average or heterogeneous treatment effects of intensive management one year after enrollment. The recursive partitioning algorithm identified variation in effects by risk score, homelessness, and whether the patient had multiple residences in a year. Within each distinct subgroup, the effect of intensive management was not statistically significant.
Primary care intensive management did not affect acute care use of high-risk patients on average or differentially for patients defined by various demographic, economic, and social characteristics.
Reducing acute care use for high-risk patients is complex, and more work is required to identify patients positioned to benefit from intensive management programs.
初级保健强化管理计划利用跨学科护理团队全面满足高住院风险患者的复杂护理需求。这些计划有效性的混合证据集中在平均治疗效果上，而这些效果可能掩盖了患者亚组之间的异质治疗效果（HTEs）。我们通过患者的人口统计学、经济和社会特征来检验 HTEs。
对退伍军人事务部一项随机质量改进试验的回顾性分析。3995 名有高住院风险的初级保健患者被随机分配到初级保健强化管理组（n=1761）或常规初级保健组（n=1731）。我们使用基于模型的递归分区和预-后对照组框架，在随机分组一年后估计 ED 和住院利用的 HTEs。分割变量包括行政收集的人口统计学特征、旅行距离、共付豁免、未来住院风险评分、未经医嘱出院史、无家可归和多个居住邮政编码。
强化管理对登记后一年的急性护理利用没有平均或异质的治疗效果。递归分区算法确定了风险评分、无家可归和患者一年内是否有多个居住地的效果变化。在每个不同的亚组内，强化管理的效果在统计学上并不显著。
初级保健强化管理平均而言并未影响高风险患者的急性护理利用，也未对各种人口统计学、经济和社会特征定义的患者产生差异影响。
降低高风险患者的急性护理利用很复杂，需要进一步努力确定有资格从强化管理计划中受益的患者。
