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首页> 外文期刊>JAMA: the Journal of the American Medical Association >Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials.
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Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials.

机译：医疗保健受益人之间医疗保健协调对住院，医疗质量和医疗保健支出的影响：15个随机试验。

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CONTEXT: Medicare expenditures of patients with chronic illnesses might be reduced through improvements in care, patient adherence, and communication. OBJECTIVE: To determine whether care coordination programs reduced hospitalizations and Medicare expenditures and improved quality of care for chronically ill Medicare beneficiaries. DESIGN, SETTING, AND PATIENTS: Eligible fee-for-service Medicare patients (primarily with congestive heart failure, coronary artery disease, and diabetes) who volunteered to participate between April 2002 and June 2005 in 15 care coordination programs (each received a negotiated monthly fee per patient from Medicare) were randomly assigned to treatment or control (usual care) status. Hospitalizations, costs, and some quality-of-care outcomes were measured with claims data for 18 309 patients (n = 178 to 2657 per program) from patients' enrollment through June 2006. A patient survey 7 to 12 months after enrollment provided additional quality-of-care measures. INTERVENTIONS: Nurses provided patient education and monitoring (mostly via telephone) to improve adherence and ability to communicate with physicians. Patients were contacted twice per month on average; frequency varied widely. MAIN OUTCOME MEASURES: Hospitalizations, monthly Medicare expenditures, patient-reported and care process indicators. RESULTS: Thirteen of the 15 programs showed no significant (P<.05) differences in hospitalizations; however, Mercy had 0.168 fewer hospitalizations per person per year (90% confidence interval [CI], -0.283 to -0.054; 17% less than the control group mean, P=.02) and Charlestown had 0.118 more hospitalizations per person per year (90% CI, 0.025-0.210; 19% more than the control group mean, P=.04). None of the 15 programs generated net savings. Treatment group members in 3 programs (Health Quality Partners [HQP], Georgetown, Mercy) had monthly Medicare expenditures less than the control group by 9% to 14% (-Dollars 84; 90% CI, -Dollars 171 to Dollars 4; P=.12; -Dollars 358; 90% CI, -Dollars 934 to Dollars 218; P=.31; and -Dollars 112; 90% CI, -Dollars 231 to Dollars 8; P=.12; respectively). Savings offset fees for HQP and Georgetown but not for Mercy; Georgetown was too small to be sustainable. These programs had favorable effects on none of the adherence measures and only a few of many quality of care indicators examined. CONCLUSIONS: Viable care coordination programs without a strong transitional care component are unlikely to yield net Medicare savings. Programs with substantial in-person contact that target moderate to severe patients can be cost-neutral and improve some aspects of care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00627029.
机译：背景：慢性病患者的医疗保险支出可通过改善护理，患者依从性和沟通来减少。目的：确定护理协调计划是否减少了慢性病医疗保险受益人的住院和医疗保险支出，并提高了医疗质量。设计，地点和患者：在2002年4月至2005年6月之间自愿参加15个护理协调计划（每个人每月均经过协商的自愿参加）的合格的付费医疗保险患者（主要患有充血性心力衰竭，冠状动脉疾病和糖尿病）每位来自Medicare的患者的费用）被随机分配为治疗或对照（常规护理）状态。根据入组至2006年6月的18 309例患者（每个程序n = 178至2657）的索赔数据，测量了住院，费用和某些护理质量结局。入组后7到12个月的患者调查提供了更高的质量护理措施。干预措施：护士（主要通过电话）提供了患者教育和监控，以提高依从性和与医生沟通的能力。平均每月接触患者两次;频率变化很大。主要观察指标：住院，每月医疗保险支出，患者报告和护理过程指标。结果：15个项目中有13个项目的住院治疗无显着差异（P <.05）。但是，Mercy的人均每年住院治疗次数减少了0.168（90％置信区间[-CI]，-0.283至-0.054;比对照组的平均值低17％，P = .02），而Charlestown的人均每年住院治疗次数增加了0.118 （90％CI，0.025-0.210;比对照组平均水平高19％，P = .04）。 15个程序中没有一个产生净节省。 3个计划（健康质量合作伙伴[HQP]，乔治敦，Mercy）的治疗组成员的每月医疗保险支出比对照组少9％至14％（-84美元; 90％CI; -171美元至4美元; P = .12; -358美元; 90％CI，-934美元兑换218美元; P = .31;和-112美元; 90％CI，-231美元至8美元兑换美元; P = .12; HQP和Georgetown节省的抵消费用，但Mercy则没有;乔治敦太小，难以承受。这些计划对任何一项依从性措施都没有产生有利的影响，并且对许多护理质量指标中的只有少数有影响。结论：没有强有力的过渡护理组成部分的可行的护理协调计划不太可能产生净的Medicare节省。针对中度至重度患者的大量面对面交流计划可以节省成本，并改善某些方面的护理。试验注册：clinicaltrials.gov标识符：NCT00627029。

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