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Abstract：
The Veterans Health Administration (VHA) conducted a randomized quality improvement evaluation to determine whether augmenting patient-centered medical homes with Primary care Intensive Management (PIM) decreased utilization of acute care and health care costs among patients at high risk for hospitalization. PIM was cost-neutral in the first year; we analyzed changes in utilization and costs in the second year.
VHA administrative data for five demonstration sites from August 2013 to March 2019.
Administrative data extracted from VHA\'s Corporate Data Warehouse.
Veterans with a risk of 90-day hospitalization in the top 10th percentile and recent hospitalization or emergency department (ED) visit were randomly assigned to usual primary care vs primary care augmented by PIM. PIM included interdisciplinary teams, comprehensive patient assessment, intensive case management, and care coordination services. We compared the change in mean VHA inpatient and outpatient utilization and costs (including PIM expenses) per patient for the 12-month period before randomization and 13-24 months after randomization for PIM vs usual care using difference-in-differences.
Both PIM patients (n = 1902) and usual care patients (n = 1882) had a mean of 5.6 chronic conditions. PIM patients had a greater number of primary care visits compared to those in usual care (mean 4.6 visits/patient/year vs 3.7 visits/patient/year, p < 0.05), but ED visits (p = 0.45) and hospitalizations (p = 0.95) were not significantly different. We found a small relative increase in outpatient costs among PIM patients compared to those in usual care (mean difference + $928/patient/year, p = 0.053), but no significant differences in mean inpatient costs (+$245/patient/year, p = 0.97). Total mean health care costs were similar between the two groups during the second year (mean difference + $1479/patient/year, p = 0.73).
Approaches that target patients solely based on the high risk of hospitalization are unlikely to reduce acute care use or total costs in VHA, which already offers patient-centered medical homes.
VHA administrative data for five demonstration sites from August 2013 to March 2019.
Administrative data extracted from VHA\'s Corporate Data Warehouse.
Veterans with a risk of 90-day hospitalization in the top 10th percentile and recent hospitalization or emergency department (ED) visit were randomly assigned to usual primary care vs primary care augmented by PIM. PIM included interdisciplinary teams, comprehensive patient assessment, intensive case management, and care coordination services. We compared the change in mean VHA inpatient and outpatient utilization and costs (including PIM expenses) per patient for the 12-month period before randomization and 13-24 months after randomization for PIM vs usual care using difference-in-differences.
Both PIM patients (n = 1902) and usual care patients (n = 1882) had a mean of 5.6 chronic conditions. PIM patients had a greater number of primary care visits compared to those in usual care (mean 4.6 visits/patient/year vs 3.7 visits/patient/year, p < 0.05), but ED visits (p = 0.45) and hospitalizations (p = 0.95) were not significantly different. We found a small relative increase in outpatient costs among PIM patients compared to those in usual care (mean difference + $928/patient/year, p = 0.053), but no significant differences in mean inpatient costs (+$245/patient/year, p = 0.97). Total mean health care costs were similar between the two groups during the second year (mean difference + $1479/patient/year, p = 0.73).
Approaches that target patients solely based on the high risk of hospitalization are unlikely to reduce acute care use or total costs in VHA, which already offers patient-centered medical homes.
摘要：
退伍军人健康管理局（VHA）进行了一项随机质量改进评估，以确定通过初级保健强化管理（PIM）来扩大以患者为中心的医疗之家是否会降低住院高危患者对急性护理和医疗费用的利用。PIM在第一年是成本中性的；我们在第二年分析了利用率和成本的变化。
2013年8月至2019年3月五个示范点的VHA管理数据。
从VHA的企业数据仓库中提取的管理数据。
在第10百分位数中有90天住院风险且最近住院或急诊（ED）就诊的退伍军人被随机分配到常规初级保健与PIM增强的初级保健。PIM包括跨学科团队，全面的患者评估，强化病例管理，护理协调服务。我们使用差异比较了随机分组前12个月和随机分组后13-24个月的平均VHA住院和门诊患者的平均使用和费用（包括PIM费用）与常规治疗的差异。
PIM患者（n=1902）和常规护理患者（n=1882）的慢性疾病平均为5.6。与常规护理相比，PIM患者的初级护理就诊次数更多（平均4.6次/患者/年vs3.7次/患者/年，p<0.05)，但ED访视(p=0.45)和住院(p=0.95)没有显著差异.我们发现，与常规护理相比，PIM患者的门诊费用略有相对增加（平均差异为928美元/患者/年，p=0.053),但平均住院费用没有显著差异(+245美元/患者/年，p=0.97）。在第二年，两组之间的总平均医疗保健费用相似(平均差异+1479美元/患者/年，p=0.73）。
仅基于住院高风险针对患者的方法不太可能减少VHA的急性护理使用或总成本。它已经提供了以病人为中心的医疗之家。
2013年8月至2019年3月五个示范点的VHA管理数据。
从VHA的企业数据仓库中提取的管理数据。
在第10百分位数中有90天住院风险且最近住院或急诊（ED）就诊的退伍军人被随机分配到常规初级保健与PIM增强的初级保健。PIM包括跨学科团队，全面的患者评估，强化病例管理，护理协调服务。我们使用差异比较了随机分组前12个月和随机分组后13-24个月的平均VHA住院和门诊患者的平均使用和费用（包括PIM费用）与常规治疗的差异。
PIM患者（n=1902）和常规护理患者（n=1882）的慢性疾病平均为5.6。与常规护理相比，PIM患者的初级护理就诊次数更多（平均4.6次/患者/年vs3.7次/患者/年，p<0.05)，但ED访视(p=0.45)和住院(p=0.95)没有显著差异.我们发现，与常规护理相比，PIM患者的门诊费用略有相对增加（平均差异为928美元/患者/年，p=0.053),但平均住院费用没有显著差异(+245美元/患者/年，p=0.97）。在第二年，两组之间的总平均医疗保健费用相似(平均差异+1479美元/患者/年，p=0.73）。
仅基于住院高风险针对患者的方法不太可能减少VHA的急性护理使用或总成本。它已经提供了以病人为中心的医疗之家。
