A cluster-based approach for integrating clinical management of Medicare beneficiaries with multiple chronic conditions
A cluster-based approach for integrating clinical management of Medicare beneficiaries with multiple chronic conditions
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DOI：
10.1371/journal.pone.0217696
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发表时间：
2019-06-19
期刊：
影响因子：
3.7
通讯作者：
Sinopoli, Angelo
中科院分区：
文献类型：
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作者：
Egan, Brent M.;Sutherland, Susan E.;Sinopoli, Angelo
大约28%的成年人患有≥ 3种慢性疾病（CC），占美国医疗保健费用的三分之二，并且通常具有次优结果。尽管2001年医学研究所建议整合多种CC的指南，但进展甚微。大量的独特的组合的CC可能会限制progress.Methods和findingsTo确定是否主要CC隔离差异有限的群体，电子健康记录和医疗保险支付索赔数据进行了检查，在一个负责任的医疗机构与44，645医疗保险受益人连续参加整个2015年。从诊断代码中获得预测临床结局的CC。凝聚层次聚类定义了13组具有相似的CC组内模式，并命名为最常见的CC。两组，充血性心力衰竭（CHF）和肾脏疾病（CKD），包括23%的受益人具有非常高的CC负担（分别为10.5和8.1 CC/受益人）。五组54%的受益人有较高的CC负担，范围从7.1到5.9（降序：神经，糖尿病，癌症，心血管，慢性肺）。六组23%的受益人有一个中低CC负担范围从4.7到0.4（行为健康，肥胖，骨关节炎，高血压，高脂血症，“其他”）。高血压和高脂血症在各组中很常见，而80%的CHF分为CHF组，85%的CKD分为CKD和CHF组，82%的癌症分为癌症、CHF和CKD组，85%的神经系统疾病分为神经、CHF和CKD组。行为健康诊断仅在CC负担高的群体中常见。的CC/受益人的数量解释了36%的方差（R-2 = 0.36）在支付的索赔/benefit.ConclusionsIdentifying的CC，不成比例地驱动成本的高负担的群体数量有限，可能有助于通知综合管理所需的实际数量的综合准则和资源。集群知情指南整合可以提高护理质量和结果，同时降低成本。
BackgroundApproximately 28% of adults have >= 3 chronic conditions (CCs), accounting for two-thirds of U.S. healthcare costs, and often having suboptimal outcomes. Despite Institute of Medicine recommendations in 2001 to integrate guidelines for multiple CCs, progress is minimal. The vast number of unique combinations of CCs may limit progress.Methods and findingsTo determine whether major CCs segregate differentially in limited groups, electronic health record and Medicare paid claims data were examined in one accountable care organization with 44,645 Medicare beneficiaries continuously enrolled throughout 2015. CCs predicting clinical outcomes were obtained from diagnostic codes. Agglomerative hierarchical clustering defined 13 groups having similar within group patterns of CCs and named for the most common CC. Two groups, congestive heart failure (CHF) and kidney disease (CKD), included 23% of beneficiaries with a very high CC burden (10.5 and 8.1 CCs/beneficiary, respectively). Five groups with 54% of beneficiaries had a high CC burden ranging from 7.1 to 5.9 (descending order: neurological, diabetes, cancer, cardiovascular, chronic pulmonary). Six groups with 23% of beneficiaries had an intermediate-low CC burden ranging from 4.7 to 0.4 (behavioral health, obesity, osteoarthritis, hypertension, hyperlipidemia, 'other'). Hypertension and hyperlipidemia were common across groups, whereas 80% of CHF segregated to the CHF group, 85% of CKD to CKD and CHF groups, 82% of cancer to Cancer, CHF, and CKD groups, and 85% of neurological disorders to Neuro, CHF, and CKD groups. Behavioral health diagnoses were common only in groups with a high CC burden. The number of CCs/beneficiary explained 36% of the variance (R-2 = 0.36) in claims paid/beneficiary.ConclusionsIdentifying a limited number of groups with high burdens of CCs that disproportionately drive costs may help inform a practical number of integrated guidelines and resources required for comprehensive management. Cluster informed guideline integration may improve care quality and outcomes, while reducing costs.