Promoting Self-Care with Telehomecare: Impact on Outcome

在所有成年患者群体中，心力衰竭老年人的再住院率最高，估计每年的直接医疗保健支出总额超过240亿美元。1自我护理能力与这一人群的患者和成本结果的改善密切相关。远程家庭护理是一项先进的技术，旨在加强具有复杂护理需求的患者的自我护理。这一通信和临床信息系统通过提供自我监测和早期症状识别所必需的工具，使患者成为自己护理的积极伙伴。尽管远程家庭护理有可能以具有成本效益的方式提高患者的自我护理能力，但很少有研究评估其疗效。报告的研究是在引入医疗保险的家庭护理前瞻性支付系统之前进行的，并评估了除了传统家访之外的远程家庭护理的使用。没有一项研究审查了患者参与关于使用此类技术满足其医疗保健需求的决策。现有的数据表明，远程家庭护理可以改善自我护理，提高老年人心力衰竭的结果，但主要的知识差距存在的临床和成本效益的这项技术时，关于其使用的决定是与病人谈判，当它取代传统的护士访问下，最近推出的变化，在家庭保健的融资。拟议的随机临床试验旨在解决这些知识差距。拟议研究的目的是比较远程家庭护理干预（N=108）的影响，替代一些标准的家庭护理服务，旨在提高自我护理和改善老年人出院后的结果与标准的家庭护理服务单独（N=108）。患者和成本结果将包括：自我护理、医疗保健资源利用、健康状况、生活质量、满意度、获得护理的机会和成本效益。数据分析将包括连续变量的混合模型ANOVA、有序变量的ANOVA非参数类似物、离散终点的Fisher精确分析、首次再入院时间的生存分析以及Lin及其同事估计不完全随访治疗成本的方法。研究结果将有助于指导最佳使用远程家庭护理，促进自我护理在不断增长的慢性病老年人，其条件的特点是高发病率，复杂的治疗和质量差，成本结果。

Elders with heart failure have the highest rehospitalization rate of all adult patient groups, with estimated annual total direct health care expenditures exceeding $24 billion.1 Self-care ability has been strongly associated with improvements in both patient and cost outcomes for this population. Telehomecare is an advanced technology designed to enhance self-care for patients with complex care needs. This communication and clinical information system enables patients to become active partners in their own care by providing the tools essential for self-monitoring and early symptom recognition. Despite telehomecare's potential to enhance patients' self-care in a cost-effective manner, few studies have evaluated its efficacy. Reported studies were conducted prior to the introduction of Medicare's prospective payment system for home care and evaluated the use of telehomecare in addition to traditional home visits. None examined patients' involvement in decision-making regarding the use of such technology in meeting their health care needs. Available data suggest that telehomecare may improve self-care and enhance outcomes for elders with heart failure but major gaps in knowledge exist regarding the clinical and cost effectiveness of this technology when decisions regarding its use are negotiated with patients and when it substitutes for traditional nurse visits under the recently introduced changes in the financing of home health care. The proposed randomized clinical trial is designed to address these knowledge gaps. The purpose of the proposed study is to compare the effects of a telehomecare intervention (N=108) that substitutes for some standard home care services and is designed to enhance self-care and improve outcomes for elders following hospital discharge for heart failure with the effects of standard home care services alone (N=108). Patient and cost outcomes will include: self-care, health care resource utilization, health status, quality of life, satisfaction, access to care and cost effectiveness. Data analysis will include mixed model ANOVA for continuous variables, non-parametric analogues of ANOVA for ordinal variables, Fisher's exact for discrete endpoints, survival analysis for time to first readmission, and methods by Lin and colleagues for estimating treatment costs with incomplete follow-up. Findings will help guide optimal use of telehomecare in promoting self-care in the growing population of chronically ill elders whose conditions are characterized by high morbidity, complex therapies and poor quality and cost outcomes.