Health Outcomes for Complex Patients: Continuity of Care and Patient Perspectives

复杂患者的健康结果：护理的连续性和患者的观点

• 批准号: 8300741
• 负责人: ELIZABETH A BAYLISS
• 金额: $ 25.71万
• 依托单位: KAISER FOUNDATION RESEARCH INSTITUTE
• 依托单位国家: 美国
• 财政年份: 2009
• 资助国家: 美国
• 起止时间: 2009-09-01 至 2015-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8300741
• 关键词: Health; Outcomes; Complex; Patients; Continuity

Abstract The number of Americans with two or more chronic conditions will increase from 57 million to 81 million people over the next 20 years. It is not clear what constitutes optimal health outcomes for persons with multiple morbidities ('complex patients'), how to attain these outcomes, or how to measure this attainment. Both complex patients themselves and expert recommendations emphasize the need for patient-centered care including continuity of relationships with clinicians and coordination of care. However, we do not know which patient-level factors affect care outcomes, whether continuity of care should be a primary component of care for complex patients, and if so, which types of clinicians should establish those continuity relationships. To address these questions we will build on previous investigations that have concentrated on small pieces of the overall process of care for complex patients and start 'putting the pieces together' to inform practical change in our healthcare system. We hypothesize that a) subjective, patient-level factors such as financial constraints and perceived disease burden, are important in achieving desired health outcomes for complex patients; b) the effect of these patient- level factors is mediated by interpersonal continuity of care, and c) continuity of care need not be only with the primary care physician (PCP). Rather, effective interpersonal continuity of care may be provided by care managers or specialty physicians as well. In order to test these hypotheses we will assess a range of health outcomes as a function of subjective factors important to complex patients in a study population of approximately 900 adults age 65+ with 3 or more chronic medical conditions. We will combine collection of subjective data by a 2-phase survey with 2-year follow up, with substantial electronic data on patient and clinical variables including detailed encounter and continuity data. We will then develop mediational models to assess health outcomes as a function of continuity of care and patient-level factors. Although clearly a function of effective systems and policies, the focus of medical care is the patient. It will be virtually impossible to implement effective systems- or policy-level interventions to improve care without an understanding of what matters to complex patients. Coordinated, team-based care has been described as a crucial component of efficient and effective care of this population. This implies that effective continuity of care need not be focused solely on the patient-PCP relationship, but could occur with other clinicians as well. However, such 'multidimensional' continuity has never been studied with regard to patient needs or health outcomes. Results from this investigation will clarify the benefits and mechanism of a broadly recommended, but unproven process of care for complex patients.

摘要 患有两种或两种以上慢性疾病的美国人将从5700万增加到8100万人 在接下来的20年里。目前尚不清楚什么构成了多个人的最佳健康结果 发病率（“复杂患者”），如何实现这些结果，或如何衡量这种实现。两 复杂的病人本身和专家的建议强调需要以病人为中心的护理 包括与临床医生的关系的连续性和护理的协调。然而，我们不知道 患者层面的因素影响护理结果，护理的连续性是否应该是护理的主要组成部分 对于复杂的病人，如果是这样，哪些类型的临床医生应该建立这些连续性关系。到 解决这些问题，我们将建立在以前的调查，集中在小块的， 复杂患者的整体护理过程，并开始“拼凑”，以告知 我们的医疗系统 我们假设：a）主观的，患者层面的因素，如经济限制和感知疾病 在复杂患者实现期望的健康结果方面是重要的; B）这些患者的影响- 水平因素是由人际护理的连续性介导的，以及c）护理的连续性不需要只与 初级保健医生（PCP）。相反，有效的人际护理的连续性可以通过护理来提供。 管理人员或专业医生也是如此。为了验证这些假设，我们将评估一系列健康状况， 结果作为对复杂患者重要的主观因素的函数， 约900名65岁以上的成年人，患有3种或3种以上慢性疾病。我们将联合收割机的收集 通过2年随访的2阶段调查获得的主观数据， 临床变量，包括详细的遭遇和连续性数据。然后，我们将开发中介模型， 评估作为护理连续性和患者层面因素的功能的健康结果。 虽然医疗保健显然是有效制度和政策的一项功能，但其重点是病人。将 几乎不可能实施有效的系统或政策层面的干预措施，以改善护理， 了解什么对复杂的病人很重要。协调的、以团队为基础的护理被描述为一种 这是有效和高效地照顾这一群体的重要组成部分。这意味着有效的连续性护理 不需要只关注患者与PCP的关系，也可能发生在其他临床医生身上。 然而，这种“多维”的连续性从未被研究过病人的需求或健康 结果。这项调查的结果将阐明广泛推荐的， 但未经证实的治疗复杂病人的方法。