New Evaluation of Guided Care's Effect on Utilization

引导护理对利用效果的新评估

• 批准号: 7774911
• 负责人: CHARLES E BOULT
• 金额: $ 4.98万
• 依托单位: JOHNS HOPKINS UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2009
• 资助国家: 美国
• 起止时间: 2009-09-30 至 2011-09-29
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7774911
• 关键词: New; Evaluation; Guided; Care; Effect

DESCRIPTION (provided by the applicant): For older Americans with several chronic conditions, the U.S. health system is "a nightmare to navigate." The quality of care is substandard, and the costs are unsustainable. "Guided Care" is an alternative approach that provides comprehensive, patient-centered, coordinated, evidence-based, IT-enhanced care. In Guided Care, an office-based registered nurse works closely with 2-5 primary care physicians in providing chronic care services to 50-60 older patients who have chronic health conditions. The first 8 months of a 20-month multisite, cluster-randomized controlled trial (cRCT) showed that Guided Care improves the quality of chronic care and tends to reduce its net costs. Unknown, however, are the cumulative effects that Guided Care may produce after the first 20 months, when the nurse-physician teams are clinically mature and the patients' chronic conditions have been well managed. We propose to evaluate the effects of Guided Care, 20-32 months after its introduction, on chronically ill patients' use and cost of health care. We will assess its effects on: 1) patients' use of high-cost services, such as hospital care; 2) insurers' net costs for health care provided by hospitals, skilled nursing facilities and home health agencies; and 3) the utilization and costs of care for subgroups of chronically ill older persons, as defined by their morbidity levels and by the characteristics of the delivery systems, primary care practices and insurance plans through which they receive care. Upon completion of the 20-month cRCT of Guided Care (June 2008), a consortium of managed care organizations and a research center provided funding to continue Guided Care for the study participants (n=904) for an additional year (July 2008 - June 2009). During this year, the health services used by the patients in the two groups were documented through insurance claims submitted to Medicare, Kaiser Permanente, or Tricare. We will obtain copies of these claims (covered by existing data use agreements), classify them into nine service categories (e.g., hospital, skilled nursing facility, home health agency), and create a data base containing the service category, date(s), place-of-service, diagnosis and units of service associated with each claim. We will compute the ratio of the two groups' 2008-2009 use of each category of service, adjusting for demographic factors, health, function and practice site. Based on these ratios and Medicare's average payments for a unit of each service, we will then compute the difference between the groups' annual health care costs. To compare the two groups' net costs of care, we will also include the costs of providing Guided Care (i.e., the nurses' salaries, benefits, equipment, travel, communication services). Finally, we will repeat these analyses on subgroups of patients to determine which patients and which health care delivery environments benefit the most (and the least) from sustained Guided Care.

描述（由申请人提供）：对于患有多种慢性病的美国老年人来说，美国的医疗系统是“一场噩梦”。护理质量不合格，成本不可持续。 “引导护理”是一种替代方法，可提供全面、以患者为中心、协调、循证、信息技术增强的护理。在引导护理中，一名办公室注册护士与 2-5 名初级保健医生密切合作，为 50-60 名患有慢性疾病的老年患者提供慢性护理服务。一项为期 20 个月的多中心整群随机对照试验 (cRCT) 的前 8 个月表明，引导护理提高了慢性护理的质量，并倾向于降低其净成本。然而，未知的是，当护士-医生团队在临床上成熟并且患者的慢性病得到良好管理时，引导式护理在前 20 个月后可能产生的累积效应可能会产生。我们建议在引入引导式护理 20-32 个月后评估其对慢性病患者的使用和医疗保健费用的影响。我们将评估其对以下方面的影响：1）患者使用高成本服务，例如医院护理； 2) 保险公司由医院、专业护理机构和家庭保健机构提供的医疗保健的净成本； 3) 慢性病老年人亚群的护理利用和费用，根据其发病水平以及提供系统的特征、初级护理实践和他们接受护理的保险计划来定义。为期 20 个月的引导式护理 cRCT（2008 年 6 月）完成后，管理式护理组织和一个研究中心组成的联盟提供资金，以继续为研究参与者（n=904）提供一年的引导式护理（2008 年 7 月 - 2009 年 6 月）。今年，两组患者使用的医疗服务均通过向 Medicare、Kaiser Permanente 或 Tricare 提交的保险索赔记录。我们将获取这些索赔的副本（由现有数据使用协议涵盖），将其分为九个服务类别（例如医院、专业护理机构、家庭保健机构），并创建一个数据库，其中包含与每个索赔相关的服务类别、日期、服务地点、诊断和服务单位。我们将计算两组 2008-2009 年使用每种服务类别的比率，并根据人口因素、健康、功能和实践地点进行调整。根据这些比率和医疗保险对每项服务单位的平均付款，我们将计算各组每年医疗保健费用之间的差异。为了比较两组的净护理成本，我们还将包括提供引导护理的成本（即护士的工资、福利、设备、旅行、通讯服务）。最后，我们将对患者亚组重复这些分析，以确定哪些患者和哪些医疗保健提供环境从持续的引导护理中受益最多（和最少）。