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

描述（由申请人提供）：在未来20年内，患有两种或两种以上慢性病的美国人数量将从5700万增加到8100万。目前尚不清楚什么构成的人患有多种疾病（“复杂的病人”），如何实现这些结果，或如何衡量这种成就的最佳健康结果。复杂的病人本身和专家的建议都强调需要以病人为中心的护理，包括与临床医生的关系的连续性和护理的协调。然而，我们不知道哪些患者层面的因素会影响护理结果，护理的连续性是否应该成为复杂患者护理的主要组成部分，如果是这样，哪些类型的临床医生应该建立这些连续性关系。为了解决这些问题，我们将建立在以前的调查，集中在复杂患者的整体护理过程的小部分，并开始“把碎片放在一起”，以告知我们的医疗保健系统的实际变化。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，对于复杂患者实现期望的健康结果很重要; B）这些患者层面因素的影响是由人际护理的连续性介导的，以及c）护理的连续性不需要仅与初级保健医生（PCP）。相反，有效的人际护理连续性也可以由护理经理或专业医生提供。为了检验这些假设，我们将评估一系列健康结果，作为对复杂患者重要的主观因素的函数，研究人群约为900名65岁以上患有3种或3种以上慢性疾病的成年人。我们将通过2期调查和2年随访，结合联合收割机收集的主观数据，以及关于患者和临床变量的大量电子数据，包括详细的就诊和连续性数据。然后，我们将开发中介模型，以评估作为护理的连续性和患者层面因素的功能的健康结果。虽然医疗保健显然是有效制度和政策的一项功能，但其重点是病人。如果不了解什么对复杂患者至关重要，就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护理。协调的、以团队为基础的护理被描述为对这一人群进行高效和有效护理的关键组成部分。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，也可以与其他临床医生一起进行。然而，这种“多维”的连续性从未被研究过病人的需求或健康结果。这项调查的结果将阐明广泛推荐但未经证实的复杂患者护理过程的益处和机制。

DESCRIPTION (provided by applicant): 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.