A Randomized Trial of Home Self-Efficacy Enhancement

描述（由申请人提供）：背景：当前和理想的慢性疾病护理之间存在“质量鸿沟”的主要原因是我们的医疗保健系统对患者的偏好不敏感，提供者驱动，以疾病为中心。相比之下，提出的以患者为中心的护理模式的共同目标是促进患者和医疗保健系统之间的持续治疗关系。这样的关系使患者能够通过各种沟通媒体接受长期的护理，而不仅仅是通过偶尔的办公室访问。家庭保健可以促进这种关系，并改善患有各种疾病的患者的预后。家庭干预措施在照顾越来越多的慢性疾病患者和伴随的功能限制方面可能特别有用，这可能限制他们获得基于社区的干预措施。然而，比较各种家庭护理模式的有效性和成本效益的试验是有限的，其有效性背后的机制仍然不清楚。目的/假设：本研究将填补这些研究空白。研究假设是：a)与常规护理相比，三种家庭干预中的每一种都会导致患者自我效能、护理依从性和健康相关生活质量（HRQOL）的改善，但在统计学上没有差异；b)从支付方的角度来看，所有干预措施与常规护理相比都将节省成本，标准的电话干预将是最节省成本的；c)自我效能感会在依从性和HRQOL之前暂时提高。方法：这将是一项四组随机对照研究，比较三种不同的家庭护理模式和常规护理在改善慢性疾病结局方面的有效性和增量成本效益。针对的慢性疾病将是关节炎、哮喘、慢性阻塞性肺病、充血性心力衰竭、抑郁症和糖尿病。训练有素的外行将提供干预，自我效能增强计划（相对于常规护理）。模型中的家庭护理提供媒介将是亲自拜访、视频电话和标准电话。主要结果将是HRQOL和费用。意义：更好地了解家庭护理的有效性机制将促进最佳家庭干预措施的发展。研究结果将有助于决策者、支付者和提供者确定实施哪些干预措施。

DESCRIPTION (provided by applicant): Background: Key reasons for the "quality chasm" between current and ideal chronic illness care are that our health care system is insensitive to patient preferences, provider-driven, and disease-focused. By contrast, a common goal among proposed patient-centered care models is to foster continuous healing relationships between patients and the health care system. Such relationships allow patients to receive care over time via a variety of communication media, rather than just via episodic office visits. Home health care can foster such relationships and improve outcomes for patients with a variety of conditions. Home interventions may be particularly useful in caring for the growing number of people with chronic illnesses and accompanying functional limitations that might limit their access to community-based interventions. However, trials comparing the effectiveness and cost-effectiveness of the wide array of home care models are limited, and the mechanisms that underlie their effectiveness remain unclear. Aims/Hypotheses: This study will address these research gaps. The study hypotheses are: a) Each of three home interventions will result in improvements in patient self-efficacy, adherence to care, and health-related quality of life (HRQOL) compared with usual care but will not differ statistically; b) From the payer's perspective, all the interventions will be cost saving compared with usual care, and a standard telephone intervention will be the most cost saving; and c) Self-efficacy will improve temporally before adherence to care and HRQOL. Methods: This will be a randomized controlled study of four groups, comparing the effectiveness and incremental cost-effectiveness of three different home-based care models and usual care in improving chronic illness outcomes. The chronic illnesses targeted will be arthritis, asthma, chronic obstructive pulmonary disease, congestive heart failure, depression, and diabetes mellitus. Trained laypersons will deliver the interventions, a self efficacy enhancement program (vs. usual care). The home care delivery media in the models will be in person visits, videophone calls, and standard telephone calls. The primary outcomes will be HRQOL and costs. Implications: Better understanding of the mechanisms of effectiveness of home care will facilitate the development of optimal home interventions. The findings will help policymakers, payers, and providers identify which interventions to implement.