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

描述(由申请人提供)：1996年，国际移民组织将连续性护理确定为初级保健的核心属性，因为它应该导致更高质量的护理、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病的老年人。2003年，国际移民组织将连续性护理作为其全面呼吁采取国家行动改变保健质量的主要目标。护理的连续性也是2006年ACP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内容。尽管护理连续性具有中心地位，但对于护理连续性的标准评估并不存在理论驱动的衡量标准，也没有对护理连续性与随后的健康结果之间的联系进行全面评价。我们建议对我们新开发的基于医疗保险索赔的人际护理连续性衡量标准与随后的健康结果之间的关联进行全面评估。我们将通过链接来自四个来源的数据来进行评估：(1)1993年的基线和对7,447名AHEAD受试者的1995、1998、2000、2002和2004年的后续访谈；(2)NDI；(3)AHEAD受试者的县标识；以及(4)1989至2004历年的联邦医疗保险A部分和B部分索赔。我们将评估四个具体的假设：(1)有人际关系连续性的提前受试者在基线时的自测健康(SRH)水平会更高，随着时间的推移，他们的SRH轨迹下降的速度会比没有人际关系连续性的受试者更慢；(H2)有人际关系连续性的提前受试者在基线时难以获得更少的日常生活活动(ADL)、工具性ADL(IADL)和身体功能(LBF)，随着时间的推移，他们的ADL、IADL和LBF轨迹的增长速度将比没有人际关系连续性的受试者慢；(H3)在基线之后，具有人际关系连续性的提前受试者将不太可能因非卧床护理敏感情况(ACSC)而住院，并且当因ACSCs而住院时，这将比那些没有人际关系连续性的受试者发生得更晚；以及，(H4)具有人际关系连续性的提前受试者将比那些没有人际关系连续性的受试者死亡率更低，寿命更长。H1将使用混合效果模型和分层(三个级别：时间、对象、县)线性建模进行测试。H2将使用与H1类似的方法进行测试，但使用的是广义线性混合效应模型。H3将使用两水平随机效应Logistic回归模型和Cox-Frailty模型进行检验。H4将使用与H3类似的方法进行测试。我们提出了广泛的敏感性分析，我们有超过80%的能力(双尾α=0.05)来检测所有考虑中的健康结果的最小临床意义变化。医学研究所(IOM，2003)和美国医师学会(ACP，2006)提出的重组美国卫生保健提供系统的提案中，人际连续性护理的作用是核心。然而，到目前为止，还没有对护理的人际连续性进行标准评估的理论驱动的措施，也没有对人际护理的连续性与随后的健康结果之间的联系进行全面评估。在此R21应用程序中，我们建议使用我们最新开发的、基于联邦医疗保险索赔的人际护理连续性测量方法，对护理连续性与后续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.