Continuity of Care and Health Outcomes: Does It Really Matter?

护理和健康结果的连续性：真的重要吗？

• 批准号: 7463835
• 负责人: Fredric D Wolinsky
• 金额: $ 14.89万
• 依托单位: UNIVERSITY OF IOWA
• 依托单位国家: 美国
• 财政年份: 2007
• 资助国家: 美国
• 起止时间: 2007-07-15 至 2009-11-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7463835
• 关键词: Activities of Daily Living; Adherence; Aged, 80 and over; Aging; Ambulatory Care; American; American College of Physicians; Behavioral Sciences; Calendar; Caring; Cessation of life; Chronic; Clinical; Communication; Condition; Continuity of Patient Care; County; Cox Models; Data; Data Collection; Data Sources; Diagnosis; Disease; Disease Management; Elderly; Evaluation; Frequencies; Geriatrics; Gerontology; Health; Health Status; Health system; Healthcare; Hospitalization; Individual; Institute of Medicine (U.S.); Interview; Linear Models; Link; Literature; Living Wills; Logistic Regressions; Marketing; Measurement; Measures; Medical; Medicare; Medicare Part A; Medicare Part B; Methodology; Mission; Modeling; NIH Program Announcements; Netherlands; Outcome; Outpatients; Patients; Physicians; Primary Care Physician; Primary Health Care; Quality of Care; Rate; Recording of previous events; Reporting; Research; Review Literature; Role; Sampling; Source; Specific qualifier value; Standards of Weights and Measures; Structure; System; Tail; Testing; Time; Trust; Visit; Vital Status; Writing; base; behavioral/social science; burden of illness; compliance behavior; concept; data structure; follow-up; frailty; health care delivery; health care quality; indexing; mortality; programs; response

DESCRIPTION (provided by applicant): In 1996, the IOM identified continuity of care as a core attribute of primary care because it should result in better quality care, disease management, and subsequent health outcomes, especially for older adults with one or more chronic conditions. In 2003 the IOM made continuity of care a primary aim in its comprehensive call for national action to transform health care quality. Continuity of care was also the centerpiece of the ACP's 2006 call for revolutionary reforms to restructure the American health care delivery system. Despite its centrality, no theoretically- driven measure exists for the standard assessment of continuity of care, nor has there been a comprehensive evaluation of the association of continuity of care with subsequent health outcomes. We propose a comprehensive evaluation of the association between our newly developed Medicare claims-based measure of interpersonal continuity of care and subsequent health outcomes. We will conduct this evaluation by linking data from four sources: (1) the 1993 baseline and 1995, 1998, 2000, 2002, and 2004 follow-up interviews with the 7,447 AHEAD subjects; (2) the NDI; (3) county identifiers for the AHEAD subjects; and, (4) Medicare Part A and B claims for calendar years 1989 through 2004. We will evaluate four specific hypotheses: (H1) AHEAD subjects with interpersonal continuity will have higher self-rated health (SRH) levels at baseline, and over time their SRH trajectories will decline more slowly than those without interpersonal continuity; (H2) AHEAD subjects with interpersonal continuity will have difficulty with fewer activities of daily living (ADLs), instrumental ADLs (IADLs), and lower body functions (LBFs) at baseline, and over time their ADL, IADL, and LBF trajectories will increase at a slower rate than those without interpersonal continuity; (H3) AHEAD subjects with interpersonal continuity will be less likely to be hospitalized for ambulatory care sensitive conditions (ACSCs) after baseline, and when hospitalized for ACSCs this will occur later than for those without interpersonal continuity of care; and, (H4) AHEAD subjects with interpersonal continuity will have lower mortality rates and will live longer than those without interpersonal continuity. H1 will be tested using mixed effects models and hierarchical (three levels: time, subject, county) linear modeling. H2 will be tested using a similar approach to H1, but with generalized linear mixed effects models. H3 will be tested using two-level random-effects logistic regression models and Cox-frailty models. H4 will be tested using a similar approach to H3. Extensive sensitivity analyses are proposed, and we have more than 80% power (two-tailed alpha = .05) to detect minimal clinically meaningful changes for all health outcomes under consideration. The role of interpersonal continuity of care is central to proposals from the Institute of Medicine (IOM, 2003) and the American College of Physicians (ACP, 2006) for restructuring the American health care delivery system. However, until now no theoretically-driven measure has existed for the standard assessment of interpersonal continuity of care, nor has there been a comprehensive evaluation of the association of interpersonal continuity of care with subsequent health outcomes. In this R21 application, we propose to conduct a comprehensive evaluation of the association between continuity of care and subsequent health outcomes using our newly developed, Medicare claims-based measure of interpersonal continuity of care.

描述（由申请人提供）：1996年，国际移民组织将护理的连续性确定为初级保健的核心属性，因为它应该导致更好的护理质量、疾病管理和随后的健康结果，特别是对于患有一种或多种慢性疾病的老年人。2003年，移徙组织在全面呼吁采取国家行动改变保健质量时，将护理的连续性作为一项主要目标。医疗服务的连续性也是ACP在2006年呼吁对美国医疗服务体系进行革命性改革的核心内容。尽管具有中心地位，但没有理论上驱动的措施来评估护理连续性的标准，也没有对护理连续性与随后的健康结果之间的关系进行全面评估。我们建议对我们新开发的基于医疗保险索赔的人际护理连续性测量与随后的健康结果之间的关系进行全面评估。我们将通过连接四个来源的数据来进行评估：(1)1993年的基线和1995年、1998年、2000年、2002年和2004年对7,447名AHEAD受试者的随访访谈；(2) NDI；(3) AHEAD科目的县标识符；(4) 1989年至2004年历年的医疗保险A部分和B部分索赔。我们将评估四个特定的假设：（H1）人际连续性的AHEAD受试者在基线时具有更高的自评健康水平，并且随着时间的推移，他们的自评健康轨迹比没有人际连续性的受试者下降得更慢；（H2）具有人际连续性的受试者在基线时存在日常生活活动（ADL）、工具性生活活动（IADLs）和下肢功能（LBF）减少的困难，随着时间的推移，他们的ADL、IADL和LBF轨迹的增加速度比没有人际连续性的受试者慢；（H3）具有人际连续性的受试者在基线后因门诊护理敏感条件（ACSCs）住院的可能性较小，且因ACSCs住院的时间比无人际连续性护理的受试者晚；（H4）具有人际连续性的AHEAD受试者比没有人际连续性的受试者死亡率低，寿命长。H1将使用混合效应模型和层次（三个层次：时间、主题、县）线性模型进行检验。H2将使用与H1类似的方法进行测试，但使用广义线性混合效应模型。H3将采用两水平随机效应logistic回归模型和cox -脆弱性模型进行检验。H4将采用与H3类似的方法进行测试。我们提出了广泛的敏感性分析，我们有超过80%的能力（双尾α = 0.05）检测到所有考虑的健康结果的最小临床有意义的变化。人际护理连续性的作用是医学研究所（IOM, 2003）和美国医师学会（ACP, 2006）重组美国卫生保健提供系统的建议的核心。然而，到目前为止，还没有理论驱动的措施存在于人际护理连续性的标准评估中，也没有对人际护理连续性与后续健康结果的关系进行全面评估。在这份R21申请中，我们建议使用我们新开发的基于医疗保险索赔的人际护理连续性测量方法，对护理连续性与后续健康结果之间的关系进行全面评估。