A Longitudinal Telephone and Multiple Disease Management System to Improve Ambula

用于改善 Ambula 的纵向电话和多种疾病管理系统

• 批准号: 7575897
• 负责人: ROBERT H FRIEDMAN
• 金额: $ 48.42万
• 依托单位: BOSTON MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2008
• 资助国家: 美国
• 起止时间: 2008-09-30 至 2011-09-29
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7575897
• 关键词: Longitudinal; Telephone; Multiple; Disease; Management

DESCRIPTION (provided by the applicant): The aim of this study is to assess the effectiveness of Telephone-Linked Care for Complex Patients (TLC-C) in the care of patients with complex health care needs, defined as patients with multiple chronic diseases who have increased health-care utilization and other socio-economic vulnerabilities, frequently transitioning from inpatient to ambulatory care. The objective is to reduce preventable hospital utilization, improve quality of life, increase satisfaction with ambulatory care, improve disease-specific metrics, reduce net payer costs. TLC-C is a modification of an existing TLC-MD system that targets patients with multiple chronic diseases combined with a post-hospital discharge intervention (TLC-RED-Lit). TLC-C uses conversational computer telephony to monitor patients' multiple diseases between their ambulatory care visits. The system works in both routine (patient stable) and exacerbation (patient unstable) modes. The system monitors patients through "virtual visits" and detects and notifies clinicians about important clinical problems to attend to. It also promotes patient self-care (e.g., medication adherence and appointment preparation). Data collected through TLC-C are integrated into the patient's electronic health record (EHR). In emergent situations the system recommends going to the local ED. In urgent situations, an alert is sent to the clinician or to his/her coverage. Exacerbation mode is used when the patient is discharged from a hospital inpatient service or ED or has worsening symptoms. It concentrates on the exacerbating disease and monitors patient status (improved, stable, or deteriorating). Daily contact is maintained until the patient's status improves. Routine mode occurs with the patient at their baseline status and monitors the disease and the patients' self-care behaviors. A multi-method evaluation study of the patients, the providers, and the practice is proposed. This includes a two-arm randomized clinical trial of TLC-C versus usual care for patients with two or more chronic diseases, with at least one previous episode of acute hospital utilization over the last 12 months, being discharged from an urban hospital. The RCT will evaluate the system in 440 patients followed for 6 months. The primary outcome is acute hospital care utilization (unplanned hospitalizations and ED visits). Secondary outcomes include patient quality of life (EQ-5D), satisfaction (G-CAHPS), ambulatory appointment show rate and net payer costs. Disease-specific metrics (e.g., HbA1c or blood pressure) will be explored. Also to be performed are formative and summative qualitative studies of the implementation of the system, its use and performance over time, and its impact on the patients, providers, and the practice as a whole

描述（由申请人提供）：本研究的目的是评估复杂患者（TLC-C）在具有复杂医疗保健需求的患者护理中的有效性，该患者定义为患有多种慢性疾病的患者，这些患者经常从内科患者过渡到卧室。目的是减少可预防的医院利用，改善生活质量，提高对门诊护理的满意度，改善特定疾病的指标，降低净付款人成本。 TLC-C是现有的TLC-MD系统的修饰，该系统针对多种慢性疾病的患者与院后出院后干预（TLC-RED-LIT）相结合。 TLC-C使用对话计算机电话来监测患者在门诊就诊之间的多种疾病。该系统在常规（患者稳定）和加重（患者不稳定）模式下起作用。该系统通过“虚拟访问”监视患者，并检测并通知临床医生有关要解决的重要临床问题。它还促进患者自我保健（例如，药物依从性和任命准备）。通过TLC-C收集的数据已集成到患者的电子健康记录（EHR）中。在紧急情况下，系统建议去本地ED。在紧急情况下，警报将发送给临床医生或他/她的承保范围。当患者从医院住院服务或ED或症状恶化时，使用加重模式。它集中于恶化的疾病，并监视患者状况（改善，稳定或恶化）。维持每日接触，直到患者的状况提高为止。常规模式发生在患者的基线状态下，并监视疾病和患者的自我保健行为。提出了对患者，提供者和实践的多方法评估研究。这包括针对两种或多种慢性疾病的患者的TLC-C的两臂随机临床试验与通常的护理，在过去的12个月中，至少有一个急性医院利用的一集，从城市医院出院。 RCT将在440名患者中评估该系统6个月。主要结果是急性医院护理利用（计划外住院和ED访问）。次要结果包括患者的生活质量（EQ-5D），满意度（G-CAHP），卧床预约率和净付款人费用。将探讨疾病特异性指标（例如HBA1C或血压）。还需要进行系统的形成性和总结性的定性研究，该研究对系统的实施，其随着时间的使用和绩效的实施以及对患者，提供者的影响以及整个做法的影响