The Effects of Dementia CareCo-Managementon Acute Care, Hospice, and Long-Term Care Utilization
The Effects of Dementia CareCo-Managementon Acute Care, Hospice, and Long-Term Care Utilization
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DOI：
10.1111/jgs.16667
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发表时间：
2020-06-23
影响因子：
6.3
通讯作者：
Reuben, David B.
中科院分区：
文献类型：
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作者：
Jennings, Lee A.;Hollands, Simon;Reuben, David B.
背景/目标 尽管执业护士痴呆症护理共同管理已被证明可以降低按服务收费 (FFS) 医疗保险受益人的总护理成本，但节省成本的原因尚不清楚。为了进一步了解痴呆症共同管理对成本的影响，我们使用 FFS 和管理的医疗保险索赔数据，与未参与该计划的痴呆症患者相比，检查了计划参与者的急症护理利用率、长期护理入院率和临终关怀服务的使用情况。设计 准实验控制前后比较。设置城市学术医疗中心。参与者 2012 年 7 月 1 日至 2015 年 12 月 31 日期间，共有 856 名加州大学洛杉矶分校 (UCLA) 阿尔茨海默病和痴呆症护理项目患者入组，还有 3,139 名类似的 UCLA 痴呆症患者未参加该项目。使用国际疾病分类 9 代码和临床记录的自然语言处理，将比较患者确定为患有痴呆症。使用粗化精确匹配来减少干预患者和比较患者之间的协变量不平衡。干预 使用执业护士与初级保健提供者和社区组织合作的痴呆症共同管理模式。测量 2.5 年干预期内全因住院、急诊科 (ED) 就诊、重症监护病房 (ICU) 住院时间以及住院天数的每季度平均差值；入住长期护理机构；以及生命最后 6 个月的临终关怀使用。结果 接受干预的患者急诊就诊次数较少（比值比 [OR] = .80；95% 置信区间 [CI] = .66-.97），住院时间较短（发病率比 = .74；95% CI = .55-.99）。各组之间的住院或 ICU 住院时间没有显着差异。计划参与者入住长期护理机构的可能性较小（风险比 = 0.65；95% CI = 0.47-0.89），并且更有可能在生命的最后 6 个月内接受临终关怀服务（调整后 OR = 1.64；95% CI = 1.13-2.37）。结论 综合执业护士痴呆症护理共同管理减少了急诊就诊次数，缩短了住院时间，增加了临终关怀服务的使用，并延迟了长期护理的入院时间。
BACKGROUND/OBJECTIVES Although nurse practitioner dementia care co-management has been shown to reduce total cost of care for fee-for-service (FFS) Medicare beneficiaries, the reasons for cost savings are unknown. To further understand the impact of dementia co-management on costs, we examined acute care utilization, long-term care admissions, and hospice use of program enrollees as compared with persons with dementia not in the program using FFS and managed Medicare claims data. DESIGN Quasi-experimental controlled before-and-after comparison. SETTING Urban academic medical center. PARTICIPANTS A total of 856 University of California, Los Angeles (UCLA) Alzheimer's and Dementia Care program patients were enrolled between July 1, 2012, and December 31, 2015, and 3,139 similar UCLA patients with dementia not in the program. Comparison patients were identified as having dementia using International Classification of Diseases-9 codes and natural language processing of clinical notes. Coarsened exact matching was used to reduce covariate imbalance between intervention and comparison patients. INTERVENTION Dementia co-management model using nurse practitioners partnered with primary care providers and community organizations. MEASUREMENTS Average difference-in-differences per quarter over the 2.5-year intervention period for all-cause hospitalization, emergency department (ED) visits, intensive care unit (ICU) stays, and number of inpatient hospitalization days; admissions to long-term care facilities; and hospice use in the last 6 months of life. RESULTS Intervention patients had fewer ED visits (odds ratio [OR] = .80; 95% confidence interval [CI] = .66-.97) and shorter hospital length of stay (incident rate ratio = .74; 95% CI = .55-.99). There were no significant differences between groups for hospitalizations or ICU stays. Program participants were less likely to be admitted to a long-term care facility (hazard ratio = .65; 95% CI = .47-.89) and more likely to receive hospice services in the last 6 months of life (adjusted OR = 1.64; 95% CI = 1.13-2.37). CONCLUSION Comprehensive nurse practitioner dementia care co-management reduced ED visits, shortened hospital length of stay, increased hospice use, and delayed admission to long-term care.