Comparative Effectiveness of Virginia Coordinated Care versus the Traditional Saf

描述(由申请人提供)：本研究的主要目的是比较VCC的有效性，特别是初级保健部分，与传统的安全网交付系统在减少2003年1月至2009年12月期间使用弗吉尼亚联邦大学卫生系统(VCUHS)的未参保患者的急诊科使用率、医院使用率和不良健康后果方面的有效性，并关注了解该计划最有效的患者的情况和类型。这将通过一项具有三项队列比较分析的回顾队列研究来实现：(1)VCC参保人在登记后一年与登记前一年相同患者的利用情况和不良结果的比较；(2)VCC参保人与未参加VCC的类似未参保人群，特别是被归类为贫困和未参保VCUHS索赔的患者的同时利用和不良结果的比较；(3)VCC参保人按照他们与指定的初级保健提供者的接触程度进行的利用和不良结果的比较。分析将控制人口统计特征和合并症。此外，我们将在VCC内的PCMH(团体实践)之间进行比较，当入选患者的数量足够多时，可以进行统计上有效的比较。最后，将通过对患有AHRQ(根据2003年联邦医疗保险处方药改进和现代化法案第1013条)确定的MMedicare现代化法案14优先条件中的三种情况的患者进行单独分析来探索第二假设：心血管疾病、糖尿病和肺部疾病/哮喘。我们之所以选择这三种情况，是因为每种情况都可能需要急诊抢救、医院或重症监护病房的抢救、插管或导致死亡。 这项研究的次要目标是确定初级保健病例管理、护理协调和以患者为中心的初级保健模式的其他使VCC计划有效的成功和可复制的要素，并注意了解这些要素如何以及为什么对不同的患者群体至关重要。这将通过定性分析来实现，定性分析包括关键线人访谈和与四个利益攸关方群体的焦点小组：计划执行人员/领导、提供者医生、护理协调员和患者，并根据先前工作和在第一个目标下执行的分析的结果了解情况。此外，我们将对在VCC内提供PCMH的做法进行比较，当排空患者的数量足够多时，可以进行统计上有效的比较。 公共卫生相关性：本研究的主要目的是比较VCC的有效性，特别是初级保健部分，与传统的安全网交付系统在减少2003年1月至2009年12月期间使用弗吉尼亚联邦大学卫生系统(VCUHS)的未参保患者的急诊科使用率、医院使用率和不良健康后果方面的有效性。将注意了解该计划对其最有效的患者的情况和类型。这项研究的次要目标是确定初级保健病例管理、护理协调和以患者为中心的初级保健模式的其他属性中的成功和可复制的元素，使VCC计划有效。将注意了解这些因素如何以及为什么对不同的患者群体至关重要。这将通过定性分析来实现，定性分析包括关键线人访谈和与四个利益攸关方群体的焦点小组：项目主管/领导层、提供者医生、护理协调员和患者，根据先前工作和在第一个目标下执行的分析的结果来了解情况。

DESCRIPTION (provided by applicant): The primary Aim of this study is to compare the effectiveness of the VCC, particularly the primary care component, with that of a traditional safety net delivery system at reducing the frequency of emergency department utilization, hospital utilization, and adverse health outcomes among uninsured patients who used the Virginia Commonwealth University Health System (VCUHS) from January 2003- December 2009, with attention to understanding the conditions and the types of patients for which the program was most effective. This will be achieved by a retrospective cohort study featuring three comparative analyses by cohorts: (1) comparison of utilization and adverse outcomes for VCC enrolees in the year after enrolment, versus the same patients during year prior to enrollment; (2) comparison of utilization and adverse outcomes for VCC enrolees versus simultaneous utilization and health outcomes of a similar uninsured population not enrolled in VCC, specifically patients classified as indigent and uninsured on VCUHS claims; (3) comparisons of utilization and adverse outcomes for VCC enrollees by the degree they engaged their assigned primary care provider. Analyses will be controlled for demographic characteristics and comorbidity. In addition, we will perform comparisons between PCMHs (group practices) within the VCC when the number of empanelled patients is large enough to permit statistically valid comparisons. Last, a secondary hypothesis will be explored by conducting separate analyses for patients with three of the MMedicare Modernization Act 14 priority conditions identified by AHRQ (pursuant to Section 1013 of the Medicare Prescription Drug Improvement and Modernization Act of 2003): cardiovascular disease, diabetes, and pulmonary disease/asthma. We chose these three conditions because each may require ED utilization, hospital or intensive care unit utilization, intubation, or result in death. The Secondary Aim of the study is to identify the successful and replicable elements of primary care case management, care coordination, and other attributes of the patient-centered primary care model that make the VCC program effective, with attention to understanding how and why these elements are critical for different patient populations. This will be achieved by qualitative analyses, consisting of key informant interviews and focus groups with four stakeholder groups: program executives/leadership, provider physicians, care coordinators, and patients, informed by results from previous work and from analyses performed under the first Aim. In addition, we will perform comparisons between practices providing PCMHs within the VCC when the number of empanelled patients is large enough to permit statistically valid comparisons. PUBLIC HEALTH RELEVANCE: The primary Aim of this study is to compare the effectiveness of the VCC, particularly the primary care component, with that of a traditional safety net delivery system at reducing the frequency of emergency department utilization, hospital utilization, and adverse health outcomes among uninsured patients who used the Virginia Commonwealth University Health System (VCUHS) from January 2003- December 2009. Attention will be paid to understanding the conditions and the types of patients for which the program was most effective. The Secondary Aim of the study is to identify the successful and replicable elements of primary care case management, care coordination, and other attributes of the patient-centered primary care model that make the VCC program effective. Attention will be paid to understanding how and why these elements are critical for different patient populations. This will be achieved by qualitative analyses, consisting of key informant interviews and focus groups with four stakeholder groups: program executives/leadership, provider physicians, care coordinators, and patients, informed by results from previous work and from analyses performed under the first Aim.