Promoting Self-Care with Telehomecare: Impact on Outcome

在所有成年患者群体中，老年心力衰竭患者的再住院率最高，估计每年直接医疗保健支出总额超过240亿美元1自我护理能力与患者和成本结果的改善密切相关。远程家庭护理是一种先进的技术，旨在提高病人的自我护理复杂的护理需求。这种沟通和临床信息系统通过提供自我监测和早期症状识别的必要工具，使患者成为自己护理的积极伙伴。尽管远程家庭护理的潜力，以提高病人的自我护理成本效益的方式，很少有研究评估其功效。报告的研究是在引入医疗保险的家庭护理预期支付系统之前进行的，并评估了除传统家访外远程家庭护理的使用。没有一项研究调查患者参与有关利用此类技术满足其保健需求的决策。现有数据表明，远程家庭护理可以改善自我护理，提高心力衰竭老年人的治疗效果，但在与患者协商决定使用这种技术时，以及在最近对家庭保健供资进行改革时，它代替了传统的护士探访时，这种技术的临床和成本效益方面存在重大知识差距。拟议的随机临床试验旨在解决这些知识空白。本研究的目的是比较远程家庭护理干预（N=108）的效果，该干预替代了一些标准家庭护理服务，旨在增强老年人因心力衰竭出院后的自我护理和改善结果，与单独标准家庭护理服务（N=108）的效果。患者和成本结果将包括：自我护理、卫生保健资源利用、健康状况、生活质量、满意度、获得护理和成本效益。数据分析将包括连续变量的混合模型方差分析，有序变量的非参数方差分析，离散终点的Fisher精确值，第一次再入院时间的生存分析，以及Lin和同事估计不完全随访治疗费用的方法。研究结果将有助于指导远程家庭护理的最佳使用，以促进日益增长的慢性病老年人的自我护理，这些老年人的病情特点是发病率高，治疗复杂，质量差，成本低。

Elders with heart failure have the highest rehospitalization rate of all adult patient groups, with estimated annual total direct health care expenditures exceeding $24 billion.1 Self-care ability has been strongly associated with improvements in both patient and cost outcomes for this population. Telehomecare is an advanced technology designed to enhance self-care for patients with complex care needs. This communication and clinical information system enables patients to become active partners in their own care by providing the tools essential for self-monitoring and early symptom recognition. Despite telehomecare's potential to enhance patients' self-care in a cost-effective manner, few studies have evaluated its efficacy. Reported studies were conducted prior to the introduction of Medicare's prospective payment system for home care and evaluated the use of telehomecare in addition to traditional home visits. None examined patients' involvement in decision-making regarding the use of such technology in meeting their health care needs. Available data suggest that telehomecare may improve self-care and enhance outcomes for elders with heart failure but major gaps in knowledge exist regarding the clinical and cost effectiveness of this technology when decisions regarding its use are negotiated with patients and when it substitutes for traditional nurse visits under the recently introduced changes in the financing of home health care. The proposed randomized clinical trial is designed to address these knowledge gaps. The purpose of the proposed study is to compare the effects of a telehomecare intervention (N=108) that substitutes for some standard home care services and is designed to enhance self-care and improve outcomes for elders following hospital discharge for heart failure with the effects of standard home care services alone (N=108). Patient and cost outcomes will include: self-care, health care resource utilization, health status, quality of life, satisfaction, access to care and cost effectiveness. Data analysis will include mixed model ANOVA for continuous variables, non-parametric analogues of ANOVA for ordinal variables, Fisher's exact for discrete endpoints, survival analysis for time to first readmission, and methods by Lin and colleagues for estimating treatment costs with incomplete follow-up. Findings will help guide optimal use of telehomecare in promoting self-care in the growing population of chronically ill elders whose conditions are characterized by high morbidity, complex therapies and poor quality and cost outcomes.