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Association of an Asthma Improvement Collaborative With Health Care Utilization in Medicaid-Insured Pediatric Patients in an Urban Community
JAMA Pediatrics ( IF 26.1 ) Pub Date : 2017-11-01 , DOI: 10.1001/jamapediatrics.2017.2600
Carolyn M. Kercsmar 1 , Andrew F. Beck 1 , Hadley Sauers-Ford 2 , Jeffrey Simmons 1 , Brandy Wiener 2 , Lisa Crosby 2 , Susan Wade-Murphy 2 , Pamela J. Schoettker 2 , Pavan K. Chundi 2 , Zeina Samaan 1 , Mona Mansour 1
Affiliation  

Importance Asthma is the most common chronic condition of childhood. Hospitalizations and emergency department (ED) visits for asthma are more frequently experienced by minority children and adolescents and those with low socioeconomic status. Objective To reduce asthma-related hospitalizations and ED visits for Medicaid-insured pediatric patients residing in Hamilton County, Ohio. Design, Setting, and Participants From January 1, 2010, through December 31, 2015, a multidisciplinary team used quality-improvement methods and the chronic care model to conduct interventions in inpatient, outpatient, and community settings in a large, urban academic pediatric hospital in Hamilton County, Ohio. Children and adolescents aged 2 to 17 years who resided in Hamilton County, had a diagnosis of asthma, and were Medicaid insured were studied. Interventions Interventions were implemented in 3 phases: hospital-based inpatient care redesign, outpatient-based care enhancements, and community-based supports. Plan-do-study-act cycles allowed for small-scale implementation of change concepts and rapid evaluation of how such tests affected processes and outcomes of interest. Main Outcomes and Measures The study measured asthma-related hospitalizations and ED visits per 10 000 Medicaid-insured pediatric patients. Data were measured monthly on a rolling 12-month mean basis. Data from multiple previous years were used to establish a baseline. Data were tracked with annotated control charts and with interrupted time-series analysis. Results Of the estimated 36 000 children and adolescents with asthma in Hamilton County (approximately 13 000 of whom are Medicaid insured and 6000 of whom are cared for in Cincinnati Children’s Hospital primary care practices), asthma-related hospitalizations decreased from 8.1 (95% CI, 7.7-8.5) to 4.7 (95% CI, 4.3-5.1) per 10 000 Medicaid patients per month by June 30, 2014, a 41.8% (95% CI, 41.7%-42.0%) relative reduction. Emergency department visits decreased from 21.5 (95% CI, 20.6-22.3) to 12.4 (95% CI, 11.5-13.2) per 10 000 Medicaid patients per month by June 30, 2014, a 42.4% (95% CI, 42.2%-42.6%) relative reduction. Improvements were sustained for the subsequent 12 months. The proportion of patients who were rehospitalized or had a return ED visit for asthma within 30 days of an index hospitalization was reduced from 12% to 7%. The proportion of patients with documented well-controlled asthma in this study’s primary care population increased from 48% to 54%. Conclusions and Relevance An integrated, multilevel approach focused on enhancing availability and accessibility of treatments, removing barriers to adherence, mitigating multidomain risks, augmenting self-management, and creating a collaborative relationship between the family and the health care system was associated with improved asthma outcomes for a population of Medicaid-insured pediatric patients. Similar models used in accountable care organizations or across patient panels and with other chronic conditions could be feasible and warrant evaluation.

中文翻译:

城市社区医疗补助保险儿童患者哮喘改善协作与医疗保健利用的关联

重要性 哮喘是儿童期最常见的慢性病。少数族裔儿童和青少年以及社会经济地位较低的人更常因哮喘住院和急诊 (ED) 就诊。目的 减少居住在俄亥俄州汉密尔顿县的医疗补助保险儿科患者的哮喘相关住院和 ED 就诊。设计、设置和参与者 从 2010 年 1 月 1 日到 2015 年 12 月 31 日,一个多学科团队使用质量改进方法和慢性病护理模式在一家大型城市学术儿科医院的住院、门诊和社区环境中进行干预在俄亥俄州汉密尔顿县。研究了居住在汉密尔顿县的 2 至 17 岁的儿童和青少年,他们被诊断为哮喘,并且有医疗补助保险。干预 干预分 3 个阶段实施:基于医院的住院护理重新设计、基于门诊的护理改进和基于社区的支持。计划-执行-研究-行动循环允许小规模实施变更概念并快速评估此类测试如何影响感兴趣的过程和结果。主要结果和措施 该研究测量了每 10 000 名医疗补助保险儿童患者的哮喘相关住院和 ED 就诊次数。数据是在滚动的 12 个月平均基础上每月测量的。使用前几年的数据来建立基线。使用带注释的控制图和中断的时间序列分析跟踪数据。结果 在汉密尔顿县估计有 36 000 名患有哮喘的儿童和青少年(其中约 13 000 人有医疗补助保险,其中 6000 人在辛辛那提儿童医院初级保健机构接受治疗),与哮喘相关的住院率从 8.1(95% CI)下降, 7.7-8.5) 到 4.7 (95% CI, 4.3-5.1) 到 2014 年 6 月 30 日,每 10 000 名医疗补助患者每月相对减少 41.8%(95% CI,41.7%-42.0%)。截至 2014 年 6 月 30 日,每 10 000 名医疗补助患者每月急诊就诊次数从 21.5(95% CI,20.6-22.3)减少到 12.4(95% CI,11.5-13.2),下降率为 42.4%(95% CI,42.2%- 42.6%) 相对减少。在随后的 12 个月中持续改善。在指数住院后 30 天内再次住院或因哮喘再次 ED 就诊的患者比例从 12% 降至 7%。在本研究的初级保健人群中,有记录的哮喘控制良好的患者比例从 48% 增加到 54%。结论和相关性 专注于提高治疗的可用性和可及性、消除依从性障碍、减轻多领域风险、增强自我管理以及在家庭和医疗保健系统之间建立协作关系的综合、多层次方法与改善哮喘结果相关用于医疗补助保险的儿童患者群体。在负责任的医疗机构或跨患者小组以及其他慢性病患者中使用的类似模型可能是可行的,并且需要进行评估。多层次方法侧重于提高治疗的可用性和可及性、消除依从性障碍、减轻多领域风险、增强自我管理以及在家庭和医疗保健系统之间建立协作关系,这些方法与医疗补助人群的哮喘结果改善有关。有保险的儿科患者。在负责任的医疗机构或跨患者小组以及其他慢性病患者中使用的类似模型可能是可行的,并且需要进行评估。多层次方法侧重于提高治疗的可用性和可及性、消除依从性障碍、减轻多领域风险、增强自我管理以及在家庭和医疗保健系统之间建立协作关系,这与改善医疗补助人群的哮喘结果有关。有保险的儿科患者。在负责任的医疗机构或跨患者小组以及其他慢性病患者中使用的类似模型可能是可行的,并且需要进行评估。在家庭和医疗保健系统之间建立协作关系与医疗补助保险儿童患者群体的哮喘结果改善有关。在负责任的医疗机构或跨患者小组以及其他慢性病患者中使用的类似模型可能是可行的,并且需要进行评估。在家庭和医疗保健系统之间建立协作关系与医疗补助保险儿童患者群体的哮喘结果改善有关。在负责任的医疗机构或跨患者小组以及其他慢性病患者中使用的类似模型可能是可行的,并且需要进行评估。
更新日期:2017-11-01
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