Continuity and the costs of care for chronic disease.
Continuity and the costs of care for chronic disease.
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DOI：
10.1001/jamainternmed.2014.245
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发表时间：
2014-05
影响因子：
39
通讯作者：
Pollack, Craig Evan
中科院分区：
文献类型：
--
作者：
Hussey, Peter S.;Schneider, Eric C.;Rudin, Robert S.;Fox, D. Steven;Lai, Julie;Pollack, Craig Evan
更好的连续性护理有望改善患者结局，降低医疗保健成本，但与当前连续性护理模式相关的利用模式、成本和临床并发症尚未量化。衡量患有慢性病的联邦医疗保险受益人的护理连续性、成本、住院率、急诊科就诊率和并发症之间的关系。回顾性队列研究。5%的联邦医疗保险受益人的保险索赔数据。2008-2009年，医疗保险受益人经历了为期12个月的充血性心力衰竭(CHF，n=53,488)、慢性阻塞性肺疾病(COPD，n=76,520)或糖尿病(DM，n=166,654)护理。与Bice-Boxerman护理连续性(COC)指数相关的住院、急诊科就诊、并发症、护理成本，COC指数是一种衡量与感兴趣条件相关的门诊连续性护理的指标。CHF的平均COC指数为0.55(标准差为0.31)，COPD为0.60(SD为0.34)，DM为0.50(SD为0.32)。经多因素调整后，连续性水平越高，住院几率越低(COC每增加0.1，CHF、COPD和DM的优势比[OR]分别为0.94[95%CI，0.93-0.95]、0.95[95%CI，0.94-0.96]和0.95[95%CI，0.95-0.96])，急诊科就诊几率更低(OR分别为0.92[95%CI，0.91，0.92]，0.93[95%CI，0.93[95%CI]，COPD为0.92-0.93，DM为0.94[95%CI，0.93-0.94]，并发症发生率较低(三种并发症类型和三种情况的OR范围为0.92-0.96；均为宝洁0.0001指数)。在调整后的分析中，COC指数每增加0.1，CHF(95%CI，4.4%-5.0%)的发病费用降低4.7%，COPD(95%CI，6.0%-6.5%)降低6.3%，DM(95%CI，5.0%-5.2%)降低5.1%。医疗保险受益人在护理连续性方面的轻微差异与成本、利用率和并发症方面的巨大差异有关。
Better continuity of care is expected to improve patient outcomes and reduce health care costs, but patterns of utilization, costs, and clinical complications associated with the current patterns of care continuity have not been quantified. To measure the association between care continuity, costs, and rates of hospitalizations, emergency department visits, and complications for Medicare beneficiaries with chronic disease. Retrospective cohort study. Insurance claims data for a 5% sample of Medicare beneficiaries. Medicare beneficiaries experiencing a 12-month episode of care for congestive heart failure (CHF, n=53,488), chronic obstructive pulmonary disease (COPD, n=76,520) or diabetes mellitus (DM, n=166,654) in 2008–2009. Hospitalizations, emergency department visits, complications, costs of care associated with the Bice-Boxerman Continuity of Care (COC) Index, a measure of the outpatient continuity of care related to conditions of interest. The mean COC index for CHF was 0.55 (standard deviation [SD] 0.31), for COPD 0.60 (SD 0.34), and for DM 0.50 (SD 0.32). After multivariable adjustment, higher levels of continuity were associated with lower odds of inpatient hospitalization (odds ratios [OR] for a 0.1 increase in COC were 0.94 [95% CI, 0.93–0.95] for CHF, 0.95 [95% CI, 0.94–0.96] for COPD, and 0.95 [95% CI, 0.95–0.96] for DM), lower odds of emergency department visits (ORs were 0.92 [95% CI, 0.91,0.92] for CHF, 0.93 [95% CI, 0.92–0.93] for COPD, and 0.94 [95% CI, 0.93–0.94] for DM), and lower odds of complications (OR range, 0.92–0.96 across the three complication types and three conditions; all p<0.0001). For every 0.1 increase in the COC index, episode costs of care were 4.7% lower for CHF (95% CI, 4.4%–5.0%), 6.3% lower for COPD (95% CI, 6.0%–6.5%), and 5.1% lower for DM (95% CI, 5.0%–5.2%) in adjusted analyses. Modest differences in care continuity for Medicare beneficiaries are associated with sizable differences in costs, utilization, and complications.
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