New Evaluation of Guided Care's Effect on Utilization

描述（由申请人提供）：对于患有多种慢性疾病的美国老年人来说，美国的卫生系统是“一场噩梦”。护理质量不达标，费用不可持续。“引导式护理”是提供全面、以患者为中心、协调、循证、信息技术增强的护理的另一种方法。在指导护理中，一名办公室注册护士与2-5名初级保健医生密切合作，为50-60名患有慢性疾病的老年患者提供慢性护理服务。一项为期20个月的多地点、集群随机对照试验（cRCT）的前8个月表明，指导式护理提高了慢性护理的质量，并倾向于降低其净成本。然而，在最初的20个月之后，当护士-医生团队在临床上成熟并且患者的慢性疾病得到很好的控制时，引导式护理可能产生的累积效应是未知的。我们建议评估引导式护理在引入20-32个月后对慢性病患者使用和医疗保健费用的影响。我们将评估其对以下方面的影响：1)患者使用高成本服务，如医院护理；2)保险公司为医院、专业护理机构和家庭保健机构提供的保健服务支付的净费用；3)慢性病老年人亚群体的护理利用和费用，根据其发病率水平以及提供系统、初级保健做法和他们接受护理的保险计划的特点来确定。在完成为期20个月的指导式护理的cRCT（2008年6月）后，一个由管理式护理组织和一个研究中心组成的联盟为研究参与者（n=904）提供了额外一年（2008年7月至2009年6月）的指导式护理。在这一年中，两组患者使用的医疗服务通过向联邦医疗保险、凯撒医疗机构或Tricare提交的保险索赔记录下来。我们将获得这些索赔（现有数据使用协议涵盖）的副本，将其分为九个服务类别（例如，医院、熟练护理机构、家庭保健机构），并创建一个数据库，其中包含与每项索赔相关的服务类别、日期、服务地点、诊断和服务单位。我们将根据人口因素、健康状况、功能和诊所地点进行调整，计算两组在2008-2009年使用每一类服务的比率。基于这些比率和医疗保险对每项服务单位的平均支付，我们将计算各组每年医疗保健费用之间的差异。为了比较两组的护理净成本，我们还将包括提供指导护理的成本（即护士的工资、福利、设备、旅行、通信服务）。最后，我们将在患者亚组中重复这些分析，以确定哪些患者和哪些医疗服务环境从持续的指导性护理中获益最多（和最少）。

DESCRIPTION (provided by the applicant): For older Americans with several chronic conditions, the U.S. health system is "a nightmare to navigate." The quality of care is substandard, and the costs are unsustainable. "Guided Care" is an alternative approach that provides comprehensive, patient-centered, coordinated, evidence-based, IT-enhanced care. In Guided Care, an office-based registered nurse works closely with 2-5 primary care physicians in providing chronic care services to 50-60 older patients who have chronic health conditions. The first 8 months of a 20-month multisite, cluster-randomized controlled trial (cRCT) showed that Guided Care improves the quality of chronic care and tends to reduce its net costs. Unknown, however, are the cumulative effects that Guided Care may produce after the first 20 months, when the nurse-physician teams are clinically mature and the patients' chronic conditions have been well managed. We propose to evaluate the effects of Guided Care, 20-32 months after its introduction, on chronically ill patients' use and cost of health care. We will assess its effects on: 1) patients' use of high-cost services, such as hospital care; 2) insurers' net costs for health care provided by hospitals, skilled nursing facilities and home health agencies; and 3) the utilization and costs of care for subgroups of chronically ill older persons, as defined by their morbidity levels and by the characteristics of the delivery systems, primary care practices and insurance plans through which they receive care. Upon completion of the 20-month cRCT of Guided Care (June 2008), a consortium of managed care organizations and a research center provided funding to continue Guided Care for the study participants (n=904) for an additional year (July 2008 - June 2009). During this year, the health services used by the patients in the two groups were documented through insurance claims submitted to Medicare, Kaiser Permanente, or Tricare. We will obtain copies of these claims (covered by existing data use agreements), classify them into nine service categories (e.g., hospital, skilled nursing facility, home health agency), and create a data base containing the service category, date(s), place-of-service, diagnosis and units of service associated with each claim. We will compute the ratio of the two groups' 2008-2009 use of each category of service, adjusting for demographic factors, health, function and practice site. Based on these ratios and Medicare's average payments for a unit of each service, we will then compute the difference between the groups' annual health care costs. To compare the two groups' net costs of care, we will also include the costs of providing Guided Care (i.e., the nurses' salaries, benefits, equipment, travel, communication services). Finally, we will repeat these analyses on subgroups of patients to determine which patients and which health care delivery environments benefit the most (and the least) from sustained Guided Care.