Critical factors in case management: practical lessons from a cardiac case management program.
Critical factors in case management: practical lessons from a cardiac case management program.
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病例管理的关键因素：心脏病病例管理计划的实践经验教训。
DOI：
10.1089/dis.2007.103624
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发表时间：
2007
影响因子：
--
通讯作者：
Berra,Kathy
中科院分区：
文献类型：
--
作者：
Stafford,RandallS;Berra,Kathy
病例管理是慢性病护理的重要策略。通过利用非医生提供者的条件，需要持续的护理和随访，CM可以促进指南一致的护理，患者赋权，并改善生活质量。我们确定了成功实施CM所需的一系列关键因素。心连心是一项临床试验，评估CM在多种族、低收入人群中降低冠心病（CHD）风险的作用。心脏病风险升高的患者被随机分配到CM+初级护理组（212例）或仅接受初级护理组（207例）。在平均17个月的随访中，患者接受了护士和营养师的面对面访问。341例（81%）完成随访的患者的平均接触时间为14小时，每例患者的估计费用为1250美元。访问强调行为改变，危险因素监测，自我管理技能和基于指南的药物治疗。相对于单独的初级保健，CM+初级保健的平均冠心病风险概率在统计学上显著降低（10年CHD风险降低1.6%，p = 0.007）。在各个风险因素中观察到有利的变化。我们的研究结果表明，成功的CM实施依赖于选择合适的病例管理人员和投资培训，将CM整合到现有的护理系统中，划定临床决策的范围和适当的水平，使用信息系统，监测结果和成本。虽然我们的人口，环境和干预模式是独特的，但这些见解具有广泛的相关性。如果实施时注意关键因素，CM有很大的潜力，以改善慢性病护理的过程和结果。（疾病管理2007;10：197-207）
Case management (CM) is an important strategy for chronic disease care. By utilizing non-physician providers for conditions requiring ongoing care and follow-up, CM can facilitate guideline-concordant care, patient empowerment, and improvement in quality of life. We identify a series of critical factors required for successful CM implementation. Heart to Heart is a clinical trial evaluating CM for coronary heart disease (CHD) risk reduction in a multiethnic, low-income population. Patients at elevated cardiac risk were randomized to CM plus primary care (212 patients) or to primary care alone (207). Over a mean follow-up of 17 months, patients received face-to-face nurse and dietitian visits. Mean contact time was 14 hours provided at an estimated cost of $1250 per patient for the 341 (81%) patients completing follow-up. Visits emphasized behavior change, risk-factor monitoring, self-management skills, and guideline-based pharmacotherapy. A statistically significant reduction in mean Framingham risk probability occurred in CM plus primary care relative to primary care alone (1.6% decrease in 10-year CHD risk, p = 0.007). Favorable changes were noted across individual risk factors. Our findings suggest that successful CM implementation relies on choosing appropriate case managers and investing in training, integrating CM into existing care systems, delineating the scope and appropriate levels of clinical decision making, using information systems, and monitoring outcomes and costs. While our population, setting, and intervention model are unique, these insights are broadly relevant. If implemented with attention to critical factors, CM has great potential to improve the process and outcomes of chronic disease care. (Disease Management2007;10:197–207)