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: 7919372
• 负责人: ELIZABETH A BAYLISS
• 金额: $ 19.05万
• 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 2013-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7919372
• 关键词: Health; Outcomes; Complex; Patients; Continuity

DESCRIPTION (provided by applicant): 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.

描述(申请人提供)：未来20年，患有两种或两种以上慢性病的美国人将从5700万人增加到8100万人。目前还不清楚什么是患有多种疾病的人(“复杂患者”)的最佳健康结果，如何实现这些结果，或者如何衡量这种结果。复杂的患者本身和专家建议都强调需要以患者为中心的护理，包括与临床医生关系的连续性和护理的协调。然而，我们不知道哪些患者水平的因素影响护理结果，护理的连续性是否应该是复杂患者护理的主要组成部分，如果是，哪些类型的临床医生应该建立这些连续性关系。为了解决这些问题，我们将在以前调查的基础上，将重点放在复杂患者整个护理过程的小部分上，并开始将这些部分组装在一起，为我们的医疗体系提供实际变化的信息。我们假设，a)患者层面的主观因素，如经济限制和感知的疾病负担，对于复杂患者实现预期的健康结果是重要的；b)这些患者层面因素的影响是由护理的人际连续性所调节的，以及c)护理的连续性不需要仅限于初级保健医生(PCP)。相反，有效的人际连续性护理也可以由护理经理或专科医生提供。为了验证这些假设，我们将评估一系列健康结果，作为对复杂患者重要的主观因素的函数，研究人群约为900名年龄在65岁以上、患有3种或更多慢性疾病的成年人。我们将结合通过两阶段调查收集的主观数据和两年的随访，使用大量关于患者和临床变量的电子数据，包括详细的相遇和连续性数据。然后，我们将开发中介模型，以评估作为护理连续性和患者水平因素的函数的健康结果。虽然显然是有效的制度和政策的作用，但医疗保健的重点是病人。如果不了解什么对复杂的患者很重要，实施有效的系统或政策层面的干预措施来改善护理几乎是不可能的。协调的、以团队为基础的护理被描述为有效和有效地护理这一人群的关键组成部分。这意味着有效的连续性护理不需要仅仅关注患者与PCP的关系，也可能发生在其他临床医生身上。然而，关于患者需求或健康结果，这种“多维”连续性从未被研究过。这项调查的结果将阐明广泛推荐的、但未经证实的复杂患者护理过程的益处和机制。