Background & Aims

Improving care coordination for patients with high-intensity specialty care needs, such as cirrhosis, can increase quality of healthcare and reduce utilization. We examined the relationship between care concentration and risk of hospitalization for patients with cirrhosis.

Methods

We performed a retrospective cohort study of 26,006 Medicare enrollees with cirrhosis with more than 4 outpatient visits over 180 days. We collected data on 2 validated measures of care concentration: the usual provider of care (UPC) index, a measure of the proportion of a patient’s total visits that is with their most regularly seen provider, and the continuity of care (COC) index, a measure of care density and dispersion. Both use a scale of 0 to 1. Time to death or liver transplantation was evaluated using a multivariable Cox proportional hazards model. Hospital days and 30-day readmissions per person-year were evaluated in negative binomial models.

Results

The median COC score was 0.40 (interquartile range, 0.26–0.60) and the median UPC was 0.60 (interquartile range, 0.50–0.80). Increasing care concentration (based on COC and UPC index scores) were associated with increased mortality and hospitalization. The highest 25th percentile of COC and UPC scores were associated with adjusted hazard ratios for mortality of 1.20 (95% CI, 1.10–1.31) and 1.14 (95% CI, 1.06–1.24), adjusted incidence rate ratios for hospital days of 1.12 (95% CI, 1.02–1.23) and 1.10 (95% CI, 1.01–1.20), and adjusted incidence rate ratios for readmissions of 1.19 (95% CI, 1.06–1.34) and 1.12 (95% CI, 1.00–1.25), respectively.

Conclusions

Based on a study of Medicare enrollees, care concentration is low among patients with cirrhosis. However, increased concentration is associated with increased mortality and increased healthcare utilization. These data indicate that, to optimize outcomes for persons with cirrhosis, team-based care might be necessary.

中文翻译：

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在一项基于人群的肝硬化患者研究中，护理协调与生存和医疗保健利用相关。

背景与目标

改善有高强度专科护理需求（例如肝硬化）的患者的护理协调，可以提高医疗保健质量并降低利用率。我们研究了肝硬化患者的护理集中度与住院风险之间的关系。

方法

我们对 26,006 名在 180 天内有超过 4 次门诊就诊的肝硬化 Medicare 参加者进行了一项回顾性队列研究。我们收集了关于 2 个经过验证的护理集中度指标的数据：常用护理提供者 (UPC) 指数、患者最常就诊的提供者占总就诊比例的衡量标准，以及护理连续性 (COC) 指数，衡量护理密度和分散度的指标。两者都使用 0 到 1 的量表。使用多变量 Cox 比例风险模型评估死亡时间或肝移植。在负二项式模型中评估了每人年的住院天数和 30 天再入院率。

结果

COC 得分中位数为 0.40（四分位距，0.26-0.60），UPC 中位数为 0.60（四分位距，0.50-0.80）。护理集中度的提高（基于 COC 和 UPC 指数评分）与死亡率和住院率的增加有关。COC 和 UPC 评分的最高 25% 与死亡率的调整风险比为 1.20（95% CI，1.10-1.31）和 1.14（95% CI，1.06-1.24）相关，住院天数调整后的发病率比为 1.12（ 95% CI, 1.02–1.23) 和 1.10 (95% CI, 1.01–1.20)，调整后的再入院发生率比率为 1.19 (95% CI, 1.06–1.34) 和 1.12 (95% CI, 1.00,–1.25)分别。

结论

根据一项对 Medicare 参加者的研究，肝硬化患者的护理集中度较低。然而，浓度增加与死亡率增加和医疗保健利用率增加有关。这些数据表明，为了优化肝硬化患者的预后，可能需要基于团队的护理。