PDF(Pubmed)
Abstract：
BACKGROUND: Patients with unmet healthcare needs are more likely to access unscheduled care. Identifying these patients through data-driven and clinical risk stratification for active case management in primary care can help address patient need and reduce demand on acute services.
OBJECTIVE: To determine how a proactive digital healthcare system can be used to undertake comprehensive needs analysis of patients at risk of unplanned admission and mortality.
METHODS: Prospective cohort study of six general practices in a deprived UK city.
METHODS: To identify those with unmet needs, the study\'s population underwent digitally-driven risk stratification into Escalated and Non-escalated groups using seven risk factors. The Escalated group underwent further stratification using GP clinical assessment into Concern and No concern groups. The Concern group underwent Unmet Needs Analysis (UNA).
RESULTS: From 24 746 patients, 516 (2.1%) were triaged into the Concern group and 164 (0.7%) underwent UNA. These patients were more likely to be older (t = 4.69, P<0.001), female (X2 = 4.46, P<0.05), have a Patients At Risk of Re-hospitalisation (PARR) score ≥80 (X2 = 4.31, P<0.05), be a nursing home resident (X2 = 6.75, P<0.01), or on an end-of-life (EOL) register (X2 = 14.55, P<0.001). Following UNA, 143 (87.2%) patients had further review planned or were referred for further input. The majority of patients had four domains of need. In those who GPs would not be surprised if they died within the next few months, n = 69 (42.1%) were not on an EOL register.
CONCLUSIONS: This study showed how an integrated, patient-centred, digital care system working with GPs can highlight and implement resources to address the escalating care needs of complex individuals.
OBJECTIVE: To determine how a proactive digital healthcare system can be used to undertake comprehensive needs analysis of patients at risk of unplanned admission and mortality.
METHODS: Prospective cohort study of six general practices in a deprived UK city.
METHODS: To identify those with unmet needs, the study\'s population underwent digitally-driven risk stratification into Escalated and Non-escalated groups using seven risk factors. The Escalated group underwent further stratification using GP clinical assessment into Concern and No concern groups. The Concern group underwent Unmet Needs Analysis (UNA).
RESULTS: From 24 746 patients, 516 (2.1%) were triaged into the Concern group and 164 (0.7%) underwent UNA. These patients were more likely to be older (t = 4.69, P<0.001), female (X2 = 4.46, P<0.05), have a Patients At Risk of Re-hospitalisation (PARR) score ≥80 (X2 = 4.31, P<0.05), be a nursing home resident (X2 = 6.75, P<0.01), or on an end-of-life (EOL) register (X2 = 14.55, P<0.001). Following UNA, 143 (87.2%) patients had further review planned or were referred for further input. The majority of patients had four domains of need. In those who GPs would not be surprised if they died within the next few months, n = 69 (42.1%) were not on an EOL register.
CONCLUSIONS: This study showed how an integrated, patient-centred, digital care system working with GPs can highlight and implement resources to address the escalating care needs of complex individuals.
摘要：
背景：医疗需求未得到满足的患者更有可能获得计划外护理。通过数据驱动和临床风险分层识别这些患者，以在初级保健中进行积极的病例管理，可以帮助满足患者需求并减少对急性服务的需求。
目的：确定如何使用主动数字医疗系统对存在计划外入院和死亡风险的患者进行全面的需求分析。
方法：对英国一个贫困城市的六种一般做法进行前瞻性队列研究。
方法：为了确定那些需求未得到满足的人，研究人群使用7个危险因素进行数字驱动的风险分层,分为已升级和未升级组.升级组使用GP临床评估进一步分层，分为关注组和不关注组。关注小组接受了未满足需求分析（UNA）。
结果：来自24746名患者，516（2.1％）被分入关注组，164（0.7％）接受了UNA。这些患者年龄较大(t=4.69,P<0.001),女性（X2=4.46，P<0.05），有再次住院风险的患者（PARR）评分≥80（X2=4.31，P<0.05），成为养老院居民(X2=6.75，P<0.01)，或在寿命终止(EOL)寄存器上(X2=14.55，P<0.001)。在UNA之后，143名（87.2%）患者计划进行进一步检查或转介进行进一步输入。大多数患者有四个需求领域。如果全科医生在接下来的几个月内去世，他们不会感到惊讶，n=69(42.1%)不在EOL登记上。
结论：这项研究表明，以病人为中心,与全科医生合作的数字护理系统可以突出显示和实施资源，以解决复杂个人不断升级的护理需求。
目的：确定如何使用主动数字医疗系统对存在计划外入院和死亡风险的患者进行全面的需求分析。
方法：对英国一个贫困城市的六种一般做法进行前瞻性队列研究。
方法：为了确定那些需求未得到满足的人，研究人群使用7个危险因素进行数字驱动的风险分层,分为已升级和未升级组.升级组使用GP临床评估进一步分层，分为关注组和不关注组。关注小组接受了未满足需求分析（UNA）。
结果：来自24746名患者，516（2.1％）被分入关注组，164（0.7％）接受了UNA。这些患者年龄较大(t=4.69,P<0.001),女性（X2=4.46，P<0.05），有再次住院风险的患者（PARR）评分≥80（X2=4.31，P<0.05），成为养老院居民(X2=6.75，P<0.01)，或在寿命终止(EOL)寄存器上(X2=14.55，P<0.001)。在UNA之后，143名（87.2%）患者计划进行进一步检查或转介进行进一步输入。大多数患者有四个需求领域。如果全科医生在接下来的几个月内去世，他们不会感到惊讶，n=69(42.1%)不在EOL登记上。
结论：这项研究表明，以病人为中心,与全科医生合作的数字护理系统可以突出显示和实施资源，以解决复杂个人不断升级的护理需求。
