Health Outcomes for Complex Patients: Continuity of Care and Patient Perspectives

摘要 患有两种或两种以上慢性病的美国人将从5700万人增加到8100万人 在接下来的20年里。目前尚不清楚什么是多发性硬化症患者的最佳健康结果 病态(“复杂患者”)，如何实现这些结果，或如何衡量这种实现。两者都有 复杂的患者本身和专家建议强调了以患者为中心的护理的必要性 包括与临床医生关系的连续性和护理的协调。然而，我们不知道是哪一个 患者水平的因素影响护理结果，护理的连续性是否应该是护理的主要组成部分 对于复杂的患者，如果是这样的话，哪些类型的临床医生应该建立这些连续性关系。至 我们将在之前的调查的基础上解决这些问题，这些调查集中在 对复杂患者的整体护理过程，并开始将各部分拼凑在一起，以告知实际的变化 我们的医疗系统。 我们假设a)主观的、患者层面的因素，如经济限制和感知的疾病 负担，对于复杂的患者实现预期的健康结果是重要的；b)这些患者- 水平因素通过护理的人际连续性来调节，c)护理的连续性不需要仅与 初级保健医生(PCP)。相反，护理可以提供有效的人际关系连续性护理 经理或专科医生也可以。为了检验这些假设，我们将评估一系列健康状况 在一项研究人群中，结果作为对复杂患者重要的主观因素的函数 大约900名年龄在65岁以上、患有3种或3种以上慢性疾病的成年人。我们将结合以下集合 通过两个阶段的调查和两年的跟踪调查获得的主观数据，以及患者和 临床变量包括详细的相遇和连续性数据。然后，我们将开发调解模型以 评估作为护理连续性和患者水平因素的功能的健康结果。 虽然显然是有效的制度和政策的作用，但医疗保健的重点是病人。会是 几乎不可能实施有效的系统或政策层面的干预措施来改善医疗保健 理解什么对复杂的病人很重要。协调的、基于团队的护理被描述为 这是有效和有效照料这一人群的关键组成部分。这意味着有效的连续性护理 不需要只关注患者与PCP的关系，也可能发生在其他临床医生身上。 然而，关于患者的需求或健康，从来没有人研究过这种“多维”的连续性 结果。这项调查的结果将阐明广泛推荐的、 但对复杂患者的护理过程未经证实。

Abstract The number of Americans with two or more chronic conditions will increase from 57 million to 81 million people over the next 20 years. It is not clear what constitutes optimal health outcomes for persons with multiple morbidities ('complex patients'), how to attain these outcomes, or how to measure this attainment. Both complex patients themselves and expert recommendations emphasize the need for patient-centered care including continuity of relationships with clinicians and coordination of care. However, we do not know which patient-level factors affect care outcomes, whether continuity of care should be a primary component of care for complex patients, and if so, which types of clinicians should establish those continuity relationships. To address these questions we will build on previous investigations that have concentrated on small pieces of the overall process of care for complex patients and start 'putting the pieces together' to inform practical change in our healthcare system. We hypothesize that a) subjective, patient-level factors such as financial constraints and perceived disease burden, are important in achieving desired health outcomes for complex patients; b) the effect of these patient- level factors is mediated by interpersonal continuity of care, and c) continuity of care need not be only with the primary care physician (PCP). Rather, effective interpersonal continuity of care may be provided by care managers or specialty physicians as well. In order to test these hypotheses we will assess a range of health outcomes as a function of subjective factors important to complex patients in a study population of approximately 900 adults age 65+ with 3 or more chronic medical conditions. We will combine collection of subjective data by a 2-phase survey with 2-year follow up, with substantial electronic data on patient and clinical variables including detailed encounter and continuity data. We will then develop mediational models to assess health outcomes as a function of continuity of care and patient-level factors. Although clearly a function of effective systems and policies, the focus of medical care is the patient. It will be virtually impossible to implement effective systems- or policy-level interventions to improve care without an understanding of what matters to complex patients. Coordinated, team-based care has been described as a crucial component of efficient and effective care of this population. This implies that effective continuity of care need not be focused solely on the patient-PCP relationship, but could occur with other clinicians as well. However, such 'multidimensional' continuity has never been studied with regard to patient needs or health outcomes. Results from this investigation will clarify the benefits and mechanism of a broadly recommended, but unproven process of care for complex patients.