Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients Across Primary Care Facilities A Randomized Clinical Trial
Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients Across Primary Care Facilities A Randomized Clinical Trial
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DOI：
10.1001/jamainternmed.2018.4630
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发表时间：
2018-12-01
影响因子：
39
通讯作者：
Long, Judith A.
中科院分区：
文献类型：
--
作者：
Kangovi, Shreya;Mitra, Nandita;Long, Judith A.
重要性解决健康的社会决定因素一直很难卫生系统operationalize.Objective评估一个标准化的干预措施，个性化管理病人为中心的目标（IMPaCT），由社区卫生工作者（CHWs）在3个卫生系统交付。设计，设置，和参与者这2臂，单盲，多中心随机临床试验招募患者从3个初级保健设施在费城，宾夕法尼亚州，2015年1月28日至2016年3月28日。招募居住在高贫困邮政编码，没有保险或公共保险，并且诊断为2种或2种以上慢性疾病的患者，并将患者随机分配到CHW干预组或对照组（仅目标设定）。在入组后6个月和9个月进行随访评估。从2017年6月至2018年3月，采用意向治疗方法对数据进行分析。干预参与者与他们的初级保健医生设定了慢性疾病管理目标;随机分配到CHW干预组的患者接受了6个月的量身定制支持。次要结果是自评心理健康，慢性疾病控制，患者激活，患者报告的初级保健质量，和全因住院。结果在592名参与者中，370名（62.5%）为女性，平均（SD）年龄为52.6（11.1）岁。两组参与者在自我评估的身体健康方面有相似的改善（平均值[SD]，1.8 [11.2] vs 1.6 [9.9]; P = 0.89）。干预组的患者更有可能报告最高质量的护理（比值比[OR]，1.8; 95%CI，1.4-2.4;风险差[RD]，0.12; P <0.001），6个月时住院总天数减少（155天vs 345天;绝对事件率降低，69%）和9个月（300天vs 471天;绝对事件率降低，65%）。住院患者的平均住院时间较短（差异，-3.1天; 95% CI，-6.33至0.22; P = 0.06）和平均住院次数较低（差异，-0.3; 95% CI，-0.6至0.0; P = 0.07）是导致这种减少的原因。干预组患者重复住院的几率较低（OR，0.4; 95% CI，0.2-0.9; RD，-0.24; P = 0.02），包括30天再入院（OR，0.3; 95% CI，0.1-0.9; RD，-0.17;结论和相关性标准化干预并没有改善自评健康，但确实改善了患者感知的护理质量，同时减少了住院，这表明卫生系统可以使用标准化干预措施来解决健康的社会决定因素。
IMPORTANCE Addressing the social determinants of health has been difficult for health systems to operationalize.OBJECTIVE To assess a standardized intervention, Individualized Management for Patient-Centered Targets (IMPaCT), delivered by community health workers (CHWs) across 3 health systems.DESIGN, SETTING, AND PARTICIPANTS This 2-armed, single-blind, multicenter randomized clinical trial recruited patients from 3 primary care facilities in Philadelphia, Pennsylvania, between January 28, 2015, and March 28, 2016. Patients who resided in a high-poverty zip code, were uninsured or publicly insured, and who had a diagnosis for 2 or more chronic diseases were recruited, and patients were randomized to either the CHW intervention or the control arm (goal setting only). Follow-up assessments were conducted at 6 and 9 months after enrollment. Data were analyzed using an intention-to-treat approach from June 2017 to March 2018.INTERVENTION Participants set a chronic disease management goal with their primary care physician; those randomized to the CHW intervention received 6 months of tailored support.MAIN OUTCOMES AND MEASURES The primary outcome was change in self-rated physical health. The secondary outcomes were self-rated mental health, chronic disease control, patient activation, patient-reported quality of primary care, and all-cause hospitalization.RESULTS Of the 592 participants, 370 (62.5%) were female, with a mean (SD) age of 52.6 (11.1) years. Participants in both arms had similar improvements in self-rated physical health (mean [SD], 1.8 [11.2] vs 1.6 [9.9]; P = .89). Patients in the intervention group were more likely to report the highest quality of care (odds ratio [OR], 1.8; 95% CI, 1.4-2.4; risk difference [RD], 0.12; P < .001) and spent fewer total days in the hospital at 6 months (155 days vs 345 days; absolute event rate reduction, 69%) and 9 months (300 days vs 471 days; absolute event rate reduction, 65%). This reduction was driven by a shorter average length of stay (difference, -3.1 days; 95% CI, -6.33 to 0.22; P = .06) and a lower mean number of hospitalizations (difference, -0.3; 95% CI, -0.6 to 0.0; P = .07) among patients who were hospitalized. Patients in the intervention group had a lower odds of repeat hospitalizations (OR, 0.4; 95% CI, 0.2-0.9; RD, -0.24; P = .02), including 30-day readmissions (OR, 0.3; 95% CI, 0.1-0.9; RD, -0.17; P = .04).CONCLUSIONS AND RELEVANCE A standardized intervention did not improve self-rated health but did improve the patient-perceived quality of care while reducing hospitalizations, suggesting that health systems may use a standardized intervention to address the social determinants of health.