Defining Patient Complexity From the Primary Care Physician's Perspective A Cohort Study
Defining Patient Complexity From the Primary Care Physician's Perspective A Cohort Study
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DOI：
10.7326/0003-4819-155-12-201112200-00001
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发表时间：
2011-12-20
影响因子：
39.2
通讯作者：
Atlas, Steve J.
中科院分区：
文献类型：
--
作者：
Grant, Richard W.;Ashburner, Jeffrey M.;Atlas, Steve J.
背景：具有复杂健康需求的患者越来越成为卫生系统重新设计的焦点。目标：根据初级保健医生 (PCP) 的定义，描述复杂患者的特征，并将该定义与其他常用算法进行比较。设计：队列研究。设置：美国初级保健网络中的 1 个医院诊所、4 个社区卫生中心和 7 个私人诊所。参与者：40 名医生，随机审查了 120 名医生 测量：在排除他们不直接负责的患者后，PCP 指出他们认为哪些患者是复杂的。对这些患者进行了特征描述，确定了复杂性的独立预测因素，并将 PCP 定义的复杂性与 3 种基于合并症的方法（Charlson 评分、Higashi 评分以及专有的医疗保险和医疗补助服务中心算法）进行比较。结果：医生将 4302 名符合条件的患者中的 1126 名 (26.2%) 确定为复杂性，并为每位患者分配平均 2.2 个复杂性域（中位数、 2.0 [四分位数范围，1 到 3]）。心理健康和药物滥用被认为是年轻复杂患者的主要问题，而医疗决策和护理协调在老年患者中占主导地位（十年趋势 P < 0.001）。 PCP 定义的复杂性的主要独立预测因素 (P < 0.001) 包括年龄（随着年龄从 55 岁增加到 65 岁，复杂性的概率从 14.8% 增加到 19.8%）、糖尿病控制不佳（如果血红蛋白 A(1c) 水平 >= 9%，则从 12.7% 增加到 47.6%）、使用抗精神病药物（从 12.7% 增加到 31.8%）、与酒精相关的诊断（来自 12.9% 到 27.4%），保险不足（从 12.5% 到 19.2%）。当 PCP 分配与其他每种方法进行比较时，复杂患者的分类一致性范围为 26.2% 至 56.0%。局限性：结果可能无法推广到其他初级保健机构。结论：初级保健医生认为大约四分之一的患者为复杂患者。医疗、社会和行为因素都导致了 PCP 定义的复杂性。医生定义的复杂性与 3 种基于合并症的算法只有适度的一致性。
Background: Patients with complex health needs are increasingly the focus of health system redesign.Objective: To characterize complex patients, as defined by their primary care physicians (PCPs), and to compare this definition with other commonly used algorithms.Design: Cohort study.Setting: 1 hospital-based practice, 4 community health centers, and 7 private practices in a primary care network in the United States.Participants: 40 physicians who reviewed a random sample of 120 of their own patients.Measurements: After excluding patients for whom they were not directly responsible, PCPs indicated which of their patients they considered complex. These patients were characterized, independent predictors of complexity were identified, and PCP-defined complexity was compared with 3 comorbidity-based methods (Charlson score, Higashi score, and a proprietary Centers for Medicare & Medicaid Services algorithm).Results: Physicians identified 1126 of their 4302 eligible patients (26.2%) as complex and assigned a mean of 2.2 domains of complexity per patient (median, 2.0 [interquartile range, 1 to 3]). Mental health and substance use were identified as major issues in younger complex patients, whereas medical decision making and care coordination predominated in older patients (P < 0.001 for trends by decade). Major independent predictors of PCP-defined complexity (P < 0.001) included age (probability of complexity increased from 14.8% to 19.8% with age increasing from 55 to 65 years), poorly controlled diabetes (from 12.7% to 47.6% if hemoglobin A(1c) level >= 9%), use of antipsychotics (from 12.7% to 31.8%), alcohol-related diagnoses (from 12.9% to 27.4%), and inadequate insurance (from 12.5% to 19.2%). Classification agreement for complex patients ranged from 26.2% to 56.0% when PCP assignment was compared with each of the other methods.Limitation: Results may not be generalizable to other primary care settings.Conclusion: Primary care physicians identified approximately one quarter of their patients as complex. Medical, social, and behavioral factors all contributed to PCP-defined complexity. Physician-defined complexity had only modest agreement with 3 comorbidity-based algorithms.