Post-Trial Sustainability and Scalability of the Benefits of a Medical Home for High-Risk Children with Medical Complexity
Post-Trial Sustainability and Scalability of the Benefits of a Medical Home for High-Risk Children with Medical Complexity
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DOI：
10.1016/j.jpeds.2018.10.035
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发表时间：
2019-03-01
影响因子：
5.1
通讯作者：
Beyda, Rebecca M.
中科院分区：
文献类型：
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作者：
Avritscher, Elenir B. C.;Mosquera, Ricardo A.;Beyda, Rebecca M.
目的评价在我们将综合护理作为标准做法并扩大该项目后，相对于为医疗复杂的高危儿童（入组前一年>= 2次住院或>= 1次儿科重症监护病房[PICU]住院）提供综合护理的医疗之家的常规护理的可持续性。研究设计我们对每个试验治疗组（常规护理）在项目扩展后（2014年3月- 2015年6月）与临床试验期间（2011年3月- 2013年8月）观察到的严重疾病儿童（死亡、PICU入院或住院7天以上）和卫生系统成本进行了前后比较。N = 96，综合护理，N = 105；在所有接受综合护理的儿童中（n（试验后）= 233）。包括试验常规护理后过渡到综合护理的儿童和新入组的医学复杂儿童，n(trial) = 105；二次分析)。我们还将试验患者的研究结果作为两期楔形研究进行了分析。结果意向治疗分析。与常规护理组相比，试验后患严重疾病的儿童比例和费用降低或保持不变（比率比[RR]， 0.36; 95% CI, 0.20-0.64；成本比[CR]， 0.68; 95% CI, 0.28-1.68）。试验综合护理组（RR, 0.74; 95% CI, 0.39-1.41； CR. 0.67; 95% CI, 0.51-0.89）。在所有接受综合护理的儿童中（RR, 0.97; 95% Cl. 0.61-1.52； CR, 0.75; 95% CI, 0.61-0.93）。保守的楔形分析确定了在两个研究期间进行综合护理的总体益处（RR, 0.46; 95% CI, 0.30-0.72； CR, 0.64; 95% CI, 0.43-0.99）。结论：综合护理的主要益处并没有随着试验后方案的扩大而减少。
Objective To assess the sustainability of the benefits relative to usual care of a medical home providing comprehensive care for high-risk children with medical complexity (>= 2 hospitalizations or >= 1 pediatric intensive care unit [PICU] admission in the year before enrollment) after we made comprehensive care our standard practice and expanded the program.Study design We conducted pre-post comparisons of the rate of children with serious illness (death, PICU admission, or >7-day hospitalization) and health-system costs observed after program expansion (March 2014-June 2015) to those during the clinical trial (March 2011-August 2013) for each of the trial's treatment groups (usual care. n = 96, and comprehensive care, n = 105; primary analyses), and among all children given comprehensive care (n(post-trial )= 233. including trial usual care children who transitioned to comprehensive care post-trial and newly enrolled medically complex children, and n(Trial) = 105; secondary analyses). We also analyzed the findings for the trial patients as a 2-phase stepped-wedge study.Results In intent-to-treat analyses. rates of children with serious illness and costs were reduced or unchanged post-trial vs trial for the trial's usual care group (rate ratio [RR], 0.36; 95% CI, 0.20-0.64; cost ratio [CR], 0.68; 95% CI, 0.28-1.68). the trial's comprehensive care group (RR, 0.74: 95% CI, 0.39-1.41; CR. 0.67; 95% CI, 0.51-0.89). and among all children given comprehensive care (RR, 0.97; 95% Cl. 0.61-1.52; CR, 0.75; 95% CI, 0.61-0.93). Conservative stepped-wedge analyses identified overall benefits with comprehensive care across both study periods (RR, 0.46; 95% CI, 0.30-0.72; CR, 0.64; 95% CI, 0.43-0.99).Conclusions Major benefits of comprehensive care did not diminish with post-trial program expansion.