Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients A Randomized Clinical Trial
Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients A Randomized Clinical Trial
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DOI：
10.1001/jamainternmed.2016.8021
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发表时间：
2017-02-01
影响因子：
39
通讯作者：
Asch, Steven M.
中科院分区：
文献类型：
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作者：
Zulman, Donna M.;Chee, Christine Pal;Asch, Steven M.
重要性 许多组织正在为高需求患者采用强化门诊护理计划，但人们对其在已建立的以患者为中心的医疗之家的集成系统中的有效性知之甚少。 目的 评估通过强化管理计划 (ImPACT) 增强退伍军人事务部 (VA) 医疗之家（患者协调护理团队 [PACT]）如何影响高需求患者的成本、医疗保健利用率和体验。 设计、设置和参与者在单一 VA 机构进行的随机临床试验。在 583 名符合条件的高需求门诊患者中，其医疗保健费用或住院风险处于该机构前 5% 的范围内，随机选择 150 名患者进行 ImPACT；其余 433 人接受标准 PACT 护理。 干预措施 ImPACT 多学科团队通过全面的患者评估、强化病例管理、护理协调以及社会和娱乐服务来满足医疗保健需求和生活质量。 主要结果和措施 主要双重差分分析检查了 16 个月基线和 17 个月随访期内医疗保健成本以及急性和长期护理利用率的变化。二次分析评估了干预措施对 ImPACT 参与者（使用随机化作为工具）以及具有关键社会人口学和临床特征的患者的影响。使用对基线和 6 个月时进行的质量改进调查的答复来评估 ImPACT 参与者的满意度和激活水平。 结果 在分配至 ImPACT 的 140 名患者中，96 名 (69%) 参与了该计划（平均 [SD] 年龄，68.3 [14.2] 岁；89 [93%] 男性；平均 [SD] 慢性病人数，10 [4]；62 [65%] 有心理健康诊断；21 [22%]有无家可归的历史）。考虑到计划成本后，ImPACT 和 PACT 患者调整后的个人每月医疗保健支出也出现类似下降（双重差分 [SE] - 101 美元 [623 美元]），急性和长期护理利用率也是如此。在 ImPACT 后续调查的受访者中（n = 54 [56% 回复率]），52 人 (96%) 表示他们会向其他人推荐该计划，事前分析显示对 VA 护理的满意度略有提高（平均 [SD] 从 2.90 [0.72] 增加到 3.16 [0.60]；P =.04）和沟通（平均 [SD] 从 2.99 [0.74] 增加到3.18 [0.60]；P =.03）。 结论和相关性 与标准 VA 护理相比，高需求患者的强化门诊护理并没有减少急性护理的利用率或费用，尽管对参与患者的体验有积极影响。在具有完善医疗之家的综合环境中实施重症门诊护理计划可能无法避免住院或实现大量成本节省。
IMPORTANCE Many organizations are adopting intensive outpatient care programs for high-need patients, yet little is known about their effectiveness in integrated systems with established patient-centered medical homes.OBJECTIVE To evaluate how augmenting the Veterans Affairs (VA) medical home (Patient Aligned Care Teams [PACT]) with an Intensive Management program (ImPACT) influences high-need patients' costs, health care utilization, and experience.DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial at a single VA facility. Among 583 eligible high-need outpatients whose health care costs or hospitalization risk were in the top 5% for the facility, 150 were randomly selected for ImPACT; the remaining 433 received standard PACT care.INTERVENTIONS The ImPACT multidisciplinary team addressed health care needs and quality of life through comprehensive patient assessments, intensive case management, care coordination, and social and recreational services.MAIN OUTCOMES AND MEASURES Primary difference-in-difference analyses examined changes in health care costs and acute and extended care utilization over a 16-month baseline and 17-month follow-up period. Secondary analyses estimated the intervention's effect on ImPACT participants (using randomization as an instrument) and for patients with key sociodemographic and clinical characteristics. ImPACT participants' satisfaction and activation levels were assessed using responses to quality improvement surveys administered at baseline and 6 months.RESULTS Of 140 patients assigned to ImPACT, 96 (69%) engaged in the program (mean [SD] age, 68.3 [14.2] years; 89 [93%] male; mean [SD] number of chronic conditions, 10 [4]; 62 [65%] had a mental health diagnosis; 21 [22%] had a history of homelessness). After accounting for program costs, adjusted person-level monthly health care expenditures decreased similarly for ImPACT and PACT patients (difference-in-difference [SE] -$ 101 [$ 623]), as did acute and extended care utilization rates. Among respondents to the ImPACT follow-up survey (n = 54 [56% response rate]), 52 (96%) reported that they would recommend the program to others, and pre-post analyses revealed modest increases in satisfaction with VA care (mean [SD] increased from 2.90 [0.72] to 3.16 [0.60]; P =.04) and communication (mean [SD] increased from 2.99 [0.74] to 3.18 [0.60]; P =.03).CONCLUSIONS AND RELEVANCE Intensive outpatient care for high-need patients did not reduce acute care utilization or costs compared with standard VA care, although there were positive effects on experience among patients who participated. Implementing intensive outpatient care programs in integrated settings with well-established medical homesmay not prevent hospitalizations or achieve substantial cost savings.