Fries J F, McShane D
Department of Medicine, Stanford University, School of Medicine, California, USA.
West J Med. 1998 Oct;169(4):201-7.
We undertook this study to identify persons with high medical use to target them for health promotion and self-management interventions specific to their problems. We compared the reductions in cost and health risk of a health education program aimed at high-risk persons with a similar program addressed to all risk levels. We compared health risk and use in 2,586 high-risk persons with those of employee (N = 50,576) and senior (N = 39,076) groups and contrasted results in specific high-risk disease or behavior categories (modules)--arthritis, back pain, high blood pressure, diabetes mellitus, heart disease, smoking, and obesity--against each other, using validated self-report measures, over a 6-month period. Interventions were a standard generic health education program and a similar program directed at high risk individuals (Healthtrac). Health risk scores improved by 11% in the overall high-risk group compared with 9% in the employee group and 6% in the senior group. Physician use decreased by 0.8 visits per 6 months in the high-risk group compared with 0.05 and 0.15 visits, respectively, per 6 months in the employee and senior groups. Hospital stays decreased by 0.2 days per 6 months in the high-risk group compared with 0.05 days in the comparison groups. The duration of illness or confinement to home decreased by 0.9 days per 6 months in the high-risk group and 0.15 and 0.25, respectively, in the employee and senior groups. Using imputed costs of $130 per physician visit, $1,000 per hospital day, and $200 per sick day, previous year costs were $1,138 in direct costs for the high-risk groups compared with $352 and $995 in the employee and senior groups, respectively. At 6 months, direct costs were reduced by $304 in the high-risk group compared with $57 and $70 in the comparison groups. Total costs were reduced $484 in the high-risk groups compared with $87 in the employee group and $120 in the senior group. The return on investment was about 6:1 in the high-risk group compared with 4:1 in the comparison groups. Effective health education programs can result in larger changes in use and costs in high-risk persons than in unscreened persons, justifying more intensive educational interventions in high-risk groups.
我们开展这项研究是为了识别高医疗利用率人群，以便针对他们的问题开展健康促进和自我管理干预措施。我们比较了针对高危人群的健康教育项目与针对所有风险水平人群的类似项目在成本降低和健康风险降低方面的情况。我们比较了2586名高危人群与员工组（N = 50576）和老年组（N = 39076）的健康风险和医疗利用率，并使用经过验证的自我报告测量方法，在6个月的时间内，对比了特定高危疾病或行为类别（模块）——关节炎、背痛、高血压、糖尿病、心脏病、吸烟和肥胖——之间的结果。干预措施包括一个标准的通用健康教育项目和一个针对高危个体的类似项目（Healthtrac）。总体高危组的健康风险评分提高了11%，而员工组提高了9%，老年组提高了6%。高危组每6个月的医生就诊次数减少了0.8次，而员工组和老年组分别为每6个月0.05次和0.15次。高危组每6个月的住院天数减少了0.2天，而对照组为0.05天。高危组每6个月的疾病持续时间或居家时间减少了0.9天，员工组和老年组分别减少了0.15天和0.25天。使用每次医生就诊130美元、每天住院1000美元和每天病假200美元的估算成本，高危组上一年的直接成本为1138美元，而员工组和老年组分别为352美元和995美元。在6个月时，高危组的直接成本减少了304美元，而对照组分别减少了57美元和70美元。高危组的总成本减少了484美元，而员工组减少了87美元，老年组减少了120美元。高危组的投资回报率约为6:1，而对照组为4:1。有效的健康教育项目在高危人群中导致的医疗利用率和成本变化比在未筛查人群中更大，这证明对高危群体进行更密集的教育干预是合理的。
