martes, 18 de octubre de 2016

Integrated Team-Based Care and Health Care Quality, Utilization, and Cost | Geriatrics | JAMA | The JAMA Network

Integrated Team-Based Care and Health Care Quality, Utilization, and Cost | Geriatrics | JAMA | The JAMA Network

Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost

JAMA. 2016;316(8):826-834. doi:10.1001/jama.2016.11232
Importance  The value of integrated team delivery models is not firmly established.
Objective  To evaluate the association of receiving primary care in integrated team-based care (TBC) practices vs traditional practice management (TPM) practices (usual care) with patient outcomes, health care utilization, and costs.
Design  A retrospective, longitudinal, cohort study to assess the association of integrating physical and mental health over time in TBC practices with patient outcomes and costs.
Setting and Participants  Adult patients (aged ≥18 years) who received primary care at 113 unique Intermountain Healthcare Medical Group primary care practices from 2003 through 2005 and had yearly encounters with Intermountain Healthcare through 2013, including some patients who received care in both TBC and TPM practices.
Exposures  Receipt of primary care in TBC practices compared with TPM practices for patients treated in internal medicine, family practice, and geriatrics practices.
Main Outcomes and Measures  Outcomes included 7 quality measures, 6 health care utilization measures, payments to the delivery system, and program investment costs.
Results  During the study period (January 2010-December 2013), 113 452 unique patients (mean age, 56.1 years; women, 58.9%) accounted for 163 226 person-years of exposure in 27 TBC practices and 171 915 person-years in 75 TPM practices. Patients treated in TBC practices compared with those treated in TPM practices had higher rates of active depression screening (46.1% for TBC vs 24.1% for TPM; odds ratio [OR], 1.91 [95% CI, 1.75 to 2.08), adherence to a diabetes care bundle (24.6% for TBC vs 19.5% for TPM; OR, 1.26 [95% CI, 1.11 to 1.42]), and documentation of self-care plans (48.4% for TBC vs 8.7% for TPM; OR, 5.59 [95% CI, 4.27 to 7.33]), lower proportion of patients with controlled hypertension (<140/90 mm Hg) (85.0% for TBC vs 97.7% for TPM; OR, 0.87 [95% CI, 0.80 to 0.95]), and no significant differences in documentation of advanced directives (9.6% for TBC vs 9.9% for TPM; OR, 0.97 [95% CI, 0.91 to 1.03]). Per 100 person-years, rates of health care utilization were lower for TBC patients compared with TPM patients for emergency department visits (18.1 for TBC vs 23.5 for TPM; incidence rate ratio [IRR], 0.77 [95% CI, 0.74 to 0.80]), hospital admissions (9.5 for TBC vs 10.6 for TPM; IRR, 0.89 [95% CI, 0.85 to 0.94]), ambulatory care sensitive visits and admissions (3.3 for TBC vs 4.3 for TPM; IRR, 0.77 [95% CI, 0.70 to 0.85]), and primary care physician encounters (232.8 for TBC vs 250.4 for TPM; IRR, 0.93 [95% CI, 0.92 to 0.94]), with no significant difference in visits to urgent care facilities (55.7 for TBC vs 56.2 for TPM; IRR, 0.99 [95% CI, 0.97 to 1.02]) and visits to specialty care physicians (213.5 for TBC vs 217.9 for TPM; IRR, 0.98 [95% CI, 0.97 to 0.99], P > .008). Payments to the delivery system were lower in the TBC group vs the TPM group ($3400.62 for TBC vs $3515.71 for TPM; β, −$115.09 [95% CI, −$199.64 to −$30.54]) and were less than investment costs of the TBC program.
Conclusions and Relevance  Among adults enrolled in an integrated health care system, receipt of primary care at TBC practices compared with TPM practices was associated with higher rates of some measures of quality of care, lower rates for some measures of acute care utilization, and lower actual payments received by the delivery system.

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