Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost
Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost
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DOI：
10.1001/jama.2016.11232
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发表时间：
2016-08-23
影响因子：
120.7
通讯作者：
James, Brent
中科院分区：
文献类型：
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作者：
Reiss-Brennan, Brenda;Brunisholz, Kimberly D.;James, Brent
重要性的综合团队交付模式的价值是不牢固established. ObjectiveTo评估协会接受初级保健在综合团队为基础的护理（TBC）的做法与传统的做法管理（TPM）的做法设计：一个回顾性的，纵向的，一项队列研究，旨在评估TBC实践中随着时间的推移整合身心健康与患者结局和成本的相关性。（年龄>= 18岁）从2003年到2005年在113个独特的Intermountain Healthcare医疗集团初级保健诊所接受初级保健，并在2013年之前每年与Intermountain Healthcare接触，包括一些接受TBC和TPM实践护理的患者。暴露TBC实践中的初级护理与TPM实践中接受内科，家庭实践，主要结果和测量结果包括7项质量测量、6项卫生保健利用测量、对交付系统的支付和项目投资成本。（2010年1月至2013年12月），113 452例独特患者在27个TBC实践中，平均年龄为56.1岁，女性为58.9%，占163 226人-年，在75个TPM实践中，占171 915人-年。接受TBC治疗的患者与接受TPM治疗的患者相比，主动抑郁筛查率更高（TBC为46.1%，TPM为24.1%;比值比[OR]，1.91 [95% CI，1.75 - 2.08），坚持糖尿病护理包（TBC为24.6%，TPM为19.5%; OR，1.26 [95% CI，1.11 - 1.42]），并记录自我护理计划（TBC为48.4%，TPM为8.7%; OR，5.59 [95% CI，4.27 - 7.33]），高血压得到控制的患者比例较低（< 140/90 mmHg）（TBC为85.0%，TPM为97.7%; OR，0.87 [95% CI，0.80至0.95]），高级指令记录无显著差异（TBC为9.6%，TPM为9.9%; OR，0.97 [95% CI，0.91至1.03]）。每100人-年，TBC患者的急诊就诊率低于TPM患者（TBC为18.1 vs TPM为23.5;发生率比[IRR]，0.77 [95% CI，0.74 - 0.80]），住院（TBC为9.5 vs TPM为10.6; IRR，0.89 [95% CI，0.85 - 0.94]），门诊护理敏感访视和入院（TBC为3.3 vs TPM为4.3; IRR，0.77 [95% CI，0.70 - 0.85]），以及初级保健医生就诊（TBC为232.8 vs TPM为250.4; IRR，0.93 [95% CI，0.92 - 0.94]），急诊就诊率无显著差异（TBC为55.7 vs TPM为56.2; IRR，0.99 [95% CI，0.97 - 1.02]）和专科医生访视（TBC为213.5，TPM为217.9; IRR为0.98 [95% CI为0.97 - 0.99]，P > 0.008）。TBC组支付给交付系统的费用低于TPM组（TBC为3400.62美元，TPM为3515.71美元; β，-115.09美元[95%CI，-199.64至-30.54美元]），低于TBC项目的投资成本。结论和相关性在参加综合卫生保健系统的成年人中，与TPM实践相比，接受TBC实践的初级保健与某些护理质量指标的较高比率、某些急性护理利用率指标的较低比率以及交付系统收到的实际付款较低相关。
IMPORTANCE The value of integrated team delivery models is not firmly established.OBJECTIVE To evaluate the association of receiving primary care in integrated team-based care (TBC) practices vs traditional practice management (TPM) practices (usual care) with patient outcomes, health care utilization, and costs.DESIGN A retrospective, longitudinal, cohort study to assess the association of integrating physical and mental health over time in TBC practices with patient outcomes and costs.SETTING AND PARTICIPANTS Adult patients (aged >= 18 years) who received primary care at 113 unique Intermountain Healthcare Medical Group primary care practices from 2003 through 2005 and had yearly encounters with Intermountain Healthcare through 2013, including some patients who received care in both TBC and TPM practices.EXPOSURES Receipt of primary care in TBC practices compared with TPM practices for patients treated in internal medicine, family practice, and geriatrics practices.MAIN OUTCOMES AND MEASURES Outcomes included 7 quality measures, 6 health care utilization measures, payments to the delivery system, and program investment costs.RESULTS During the study period (January 2010-December 2013), 113 452 unique patients (mean age, 56.1 years; women, 58.9%) accounted for 163 226 person-years of exposure in 27 TBC practices and 171 915 person-years in 75 TPM practices. Patients treated in TBC practices compared with those treated in TPM practices had higher rates of active depression screening (46.1% for TBC vs 24.1% for TPM; odds ratio [OR], 1.91 [95% CI, 1.75 to 2.08), adherence to a diabetes care bundle (24.6% for TBC vs 19.5% for TPM; OR, 1.26 [95% CI, 1.11 to 1.42]), and documentation of self-care plans (48.4% for TBC vs 8.7% for TPM; OR, 5.59 [95% CI, 4.27 to 7.33]), lower proportion of patients with controlled hypertension (< 140/ 90mmHg) (85.0% for TBC vs 97.7% for TPM; OR, 0.87 [95% CI, 0.80 to 0.95]), and no significant differences in documentation of advanced directives (9.6% for TBC vs 9.9% for TPM; OR, 0.97 [95% CI, 0.91 to 1.03]). Per 100 person-years, rates of health care utilizationwere lower for TBC patients compared with TPM patients for emergency department visits (18.1 for TBC vs 23.5 for TPM; incidence rate ratio [IRR], 0.77 [95% CI, 0.74 to 0.80]), hospital admissions (9.5 for TBC vs 10.6 for TPM; IRR, 0.89 [95% CI, 0.85 to 0.94]), ambulatory care sensitive visits and admissions (3.3 for TBC vs 4.3 for TPM; IRR, 0.77 [95% CI, 0.70 to 0.85]), and primary care physician encounters (232.8 for TBC vs 250.4 for TPM; IRR, 0.93 [95% CI, 0.92 to 0.94]), with no significant difference in visits to urgent care facilities (55.7 for TBC vs 56.2 for TPM; IRR, 0.99 [95% CI, 0.97 to 1.02]) and visits to specialty care physicians (213.5 for TBC vs 217.9 for TPM; IRR, 0.98 [95% CI, 0.97 to 0.99], P >.008). Payments to the delivery systemwere lower in the TBC group vs the TPM group ($3400.62 for TBC vs $3515.71 for TPM; beta, -$115.09 [95% CI, -$199.64 to -$30.54]) and were less than investment costs of the TBC program.CONCLUSIONS AND RELEVANCE Among adults enrolled in an integrated health care system, receipt of primary care at TBC practices compared with TPM practices was associated with higher rates of some measures of quality of care, lower rates for some measures of acute care utilization, and lower actual payments received by the delivery system.