Perloff Jennifer, Hoyt Alex, Srinivasan Meera, Alvarez Michelle, Sobul Sam, O'Reilly-Jacob Monica
Heller School of Social Policy & Management, Brandeis University, Waltham, Massachusetts, USA.
Institute for Accountable Care, Washington, DC, USA.
J Am Geriatr Soc. 2024 Dec;72(12):3763-3772. doi: 10.1111/jgs.19182. Epub 2024 Sep 18.
As the US population ages, there is an increasing demand for home-based primary care (HBPC) by those with Alzheimer's/dementia, multiple chronic conditions, severe physical limitations, or those facing end-of life. Nurse practitioners (NPs) are increasingly providing HBPC, yet little is known about their quality of care in this unique setting.
This observational study uses Medicare claims data from 2018 to assess the quality of care for high-intensity HBPC users (5 or more visits/year) based on provider type (NP-only, physician (MD)-only, or both NP and MDs). We employ 12 quality measures from 3 care domains: access and prevention, acute care utilization, and end-of-life. Analysis includes bivariate comparisons and logistic regression models that adjust for demographic, clinical, and geographic characteristics.
Among the 574,567 beneficiaries with 5 or more HBPC visits, 37% saw an NP, 37% saw a MD, and 27% saw both NPs and MDs. In multivariate models, those receiving HBPC from an NP or both NP-MD are significantly more likely to receive a flu shot than the MD-only group, but less likely to access preventive care. NP-only care is associated with more acute care hospitalizations, avoidable ED visits, and fall-related injuries, but significantly fewer avoidable admissions. For end-of-life care, those with NP-only or both NP-MD care are significantly more likely to have an advanced directive, be in hospice in the last 3 days of life, and more likely to die in hospice. The NP group is also more likely to die in the next year.
HBPC patients are complex, with both palliative and curative needs. NPs provide almost half of HBPC in the Medicare program, to patients who are possibly sicker than those treated by physicians, with similar quality to MDs.
随着美国人口老龄化，患有阿尔茨海默病/痴呆症、多种慢性病、严重身体限制或面临临终的人群对居家初级保健（HBPC）的需求日益增加。执业护士（NP）越来越多地提供HBPC，但在这种独特环境下他们的护理质量却鲜为人知。
这项观察性研究使用2018年医疗保险索赔数据，根据提供者类型（仅NP、仅医生（MD）或NP和MD两者）评估高强度HBPC使用者（每年就诊5次或更多次）的护理质量。我们采用了来自3个护理领域的12项质量指标：就诊机会与预防、急性护理利用和临终关怀。分析包括双变量比较和调整人口统计学、临床和地理特征的逻辑回归模型。
在574567名每年进行5次或更多次HBPC就诊的受益人中，37%看过NP，37%看过MD，27%既看过NP也看过MD。在多变量模型中，接受NP或NP-MD两者提供HBPC的患者比仅看MD的组更有可能接种流感疫苗，但获得预防性护理的可能性较小。仅由NP提供的护理与更多的急性护理住院、可避免的急诊就诊和与跌倒相关的伤害相关，但可避免的入院显著减少。对于临终关怀，仅接受NP或NP-MD两者护理的患者更有可能有预先指示，在生命的最后3天接受临终关怀，并且更有可能在临终关怀机构死亡。NP组在次年死亡的可能性也更大。
HBPC患者情况复杂，既有姑息治疗需求也有治愈需求。在医疗保险计划中，NP提供了近一半的HBPC，服务对象可能比医生治疗的患者病情更重，护理质量与MD相当。
