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The Impact of the Veterans Health Administration's Home Based Primary Care on Health Services Use, Expenditures, and Mortality.

机译：退伍军人卫生管理局基于家庭的初级保健对卫生服务使用，支出和死亡率的影响。

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摘要

Background: Among patients with multiple chronic conditions, care coordination and integration remains one of the major challenges facing the U.S. health care system. A home-based, patient-centered primary care program has been offered through the Veterans Health Administration (VHA) since the 1970s for frail veterans who have difficulty accessing VHA clinics. The VHA Home Based Primary Care (VHA HBPC) aims to integrate primary care, rehabilitation, disease management, palliative care, and coordination of care for frail individuals with complex, chronic diseases within their homes. Early research suggested that VHA HBPC was associated with positive outcomes (e.g., reduced resource use and patient satisfaction). However, evidence regarding the effect of the VHA HBPC program on health services use (especially hospital and nursing home use), expenditures, and other patient outcomes remains limited. The present study is designed to fill this gap as the rise in the number of veterans with complex health care needs will likely increase in the coming decades.;Objectives: The current study aimed to examine the impact of VHA HBPC on health services use, expenditures, and mortality among a cohort of new VHA HBPC enrollees identified in the national VHA data system. The specific aims of this study were: 1) to examine the effect of VHA HBPC on major health service use (hospital, nursing home, and outpatient care) paid for by the Veterans Administration; 2) to examine the effect of VHA HBPC on total health services expenditures; and 3) to examine whether VHA HBPC enrollees experienced similar mortality and survival as compared to a matched concurrent cohort.;Methods: This study used a retrospective cohort design. A new VHA HBPC enrollee cohort (the treatment group) and a propensity matched comparison cohort (the comparison group) were identified from VHA claims in fiscal years (FY) 2009 and 2010 and were followed through FY 2012. Data on health service use, expenditures, and mortality/survival data were obtained via the VHA administrative datasets (i.e., Decision Support System, Purchased Care, and Vital Status Files). Propensity scores of being enrolled in the VHA HBPC were generated by a logistic regression model controlling for potential confounders. After 41,244 matched pairs were determined adequate through several diagnostic methods, means tests, relative risk analyses, and generalized linear models were used to estimate the effect of VHA HBPC on outcomes. Additionally, a Cox proportional hazards regression model was used to estimate the effect of VHA HBPC on survival. Subgroup analyses were conducted stratifying by age (85 and older), comorbidities (2 or more), and the receipt of palliative care. Based on the results of the original analyses, a series of sensitivity analyses were conducted that modified the described sample selection criteria and matching algorithm.;Results: Analyses of the original cohort revealed that VHA HBPC patients had significantly higher risks of being admitted into a hospital (RR 1.53, 95% CI 1.51-1.56) or nursing home (RR 1.65, CI 1.50 - 1.81). The average total expenditures during the study period were significantly higher for the VHA HBPC group as compared to the control group (;Discussion: This study found that without accounting for important covariates such as initial hospitalization, time to death, and a range of comorbidities, VHA HBPC was associated with higher health service use, higher expenditures, higher mortality, and shorter survival as compared to a similar group of patients not receiving VHA HBPC. After accounting for these factors, VHA HBPC was associated with a lower risk of nursing home use, and after six months, VHA HBPC was associated with lower risk of both nursing home and hospital use. These findings suggest that while VHA HBPC may improve quality of life and patient satisfaction through patient-centered integrated primary care, it may not generate cost savings for the healthcare system. Future research is needed to understand variation in program implementation and how this affects the impact of VHA HBPC on service use and cost. (Abstract shortened by UMI.).
机译：背景：在患有多种慢性病的患者中，护理协调和整合仍然是美国医疗保健系统面临的主要挑战之一。从1970年代起，美国退伍军人健康管理局（VHA）就为难以进入VHA诊所的体弱的退伍军人提供了以患者为中心的家庭为基础的初级保健计划。 VHA家庭基础保健（VHA HBPC）旨在整合基础保健，康复，疾病管理，姑息治疗以及对家中患有复杂，慢性疾病的体弱个体的护理协调。早期研究表明，VHA HBPC与阳性结果相关（例如，减少资源使用和患者满意度）。但是，有关VHA HBPC计划对卫生服务使用（尤其是医院和疗养院使用），支出和其他患者结果的影响的证据仍然有限。本研究旨在填补这一空白，因为在未来几十年中，具有复杂医疗保健需求的退伍军人人数可能会增加。目标：本研究旨在研究VHA HBPC对医疗服务使用，支出的影响，以及在国家VHA数据系统中识别出的一组新VHA HBPC入组者的死亡率。这项研究的具体目的是：1）研究VHA HBPC对退伍军人管理局付费的主要医疗服务使用（医院，疗养院和门诊病人）的影响； 2）研究VHA HBPC对卫生服务总支出的影响； 3）检查与匹配的同期队列相比，VHA HBPC入组者的死亡率和生存率是否相似。方法：本研究采用回顾性队列设计。从2009和2010财政年度的VHA索赔中确定了一个新的VHA HBPC登记人群（治疗组）和一个倾向匹配的比较队列（比较组），直到2012财政年度。以及死亡率/生存数据是通过VHA管理数据集（即，决策支持系统，购买的护理和生命状况文件）获得的。被纳入VHA HBPC的倾向得分是通过控制潜在混杂因素的逻辑回归模型得出的。在通过几种诊断方法，均值测试，相对风险分析和广义线性模型确定了41,244个匹配对后，使用配对线性模型来评估VHA HBPC对预后的影响。此外，使用Cox比例风险回归模型来评估VHA HBPC对生存的影响。按年龄（85岁及以上），合并症（2个或更多）和姑息治疗的接受程度进行亚组分析。根据原始分析的结果，进行了一系列敏感性分析，修改了所描述的样本选择标准和匹配算法。结果：对原始队列的分析表明，VHA HBPC患者入院的风险明显更高（RR 1.53，95％CI 1.51-1.56）或疗养院（RR 1.65，CI 1.50-1.81）。与对照组相比，VHA HBPC组在研究期间的平均总支出明显更高（;讨论：该研究发现，在不考虑重要协变量的情况下，例如初始住院，死亡时间和合并症，与未接受VHA HBPC的相似患者相比，VHA HBPC与更高的卫生服务使用率，更高的支出，更高的死亡率和更短的生存期相关联，在考虑了这些因素之后，VHA HBPC与较低的护理院使用风险相关，六个月后，VHA HBPC降低了疗养院和医院使用的风险，这些发现表明，尽管VHA HBPC可以通过以患者为中心的综合初级保健来改善生活质量和患者满意度，但可能不会节省成本对于医疗保健系统，需要进行进一步的研究以了解计划实施中的差异以及这如何影响VH的影响关于服务使用和成本的HBPC。 （摘要由UMI缩短。）。

著录项

  • 作者

    Castora-Binkley, Melissa.;

  • 作者单位

    University of South Florida.;

  • 授予单位 University of South Florida.;
  • 学科 Health care management.;Gerontology.;Public policy.;Military studies.
  • 学位 Ph.D.
  • 年度 2015
  • 页码 118 p.
  • 总页数 118
  • 原文格式 PDF
  • 正文语种 eng
  • 中图分类
  • 关键词

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