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

描述（由申请人提供）：1996年，IOM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质量护理，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，国际移民组织在其全面呼吁国家采取行动改变卫生保健质量时，将护理的连续性作为首要目标。护理的连续性也是ACP 2006年呼吁进行革命性改革以重组美国医疗保健提供系统的核心。尽管它的中心地位，没有理论驱动的措施存在的标准评估护理的连续性，也没有一个全面的评价的关联护理的连续性与随后的健康结果。我们提出了一个全面的评估，我们新开发的医疗保险索赔为基础的措施，人际护理的连续性和随后的健康结果之间的关联。我们将通过连接以下四个来源的数据进行评估：（1）1993年基线和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受试者的县标识符;以及（4）1989至2004日历年的Medicare Part A和B索赔。我们将评估四个具体的假设：（H1）具有人际连续性的AHEAD受试者在基线时将具有更高的自测健康（SRH）水平，并且随着时间的推移，他们的SRH轨迹将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AHEAD受试者将难以进行较少的日常生活活动（ADL）、工具性ADL（IADL），和较低的身体功能（LBF）在基线，随着时间的推移，他们的ADL，IADL和LBF轨迹将以较慢的速度增加比那些没有人际连续性;（H3）具有人际关系连续性的AHEAD受试者在基线后因门诊护理敏感性疾病（ACSC）住院的可能性较小，当因ACSC住院时，这将比那些没有人际连续性护理的患者发生得更晚;并且，（H4）具有人际连续性的AHEAD受试者将具有较低的死亡率，并且将比那些没有人际连续性的受试者活得更长。将使用混合效应模型和分层（三个水平：时间、受试者、县）线性模型检验H1。将使用与H1相似的方法检验H2，但使用广义线性混合效应模型。将使用两水平随机效应logistic回归模型和Cox虚弱模型检验H3。H4将使用与H3相似的方法进行测试。提出了广泛的敏感性分析，我们有超过80%的权力（双尾α = 0.05），以检测最小的临床有意义的变化，所有的健康结果正在考虑。人际护理连续性的作用是医学研究所（IOM，2003年）和美国医师学院（ACP，2006年）建议重组美国医疗保健提供系统的核心。然而，到目前为止，没有理论驱动的措施已经存在的标准评估的人际连续性的护理，也没有一个全面的评估人际连续性的护理与随后的健康结果的关联。在这个R21应用程序中，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措施，对护理连续性与随后的健康结果之间的关联进行全面评估。

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.