Impact of an Interdisciplinary Care Program on Health Outcomes in Older Patients with Multimorbidity

跨学科护理计划对患有多种疾病的老年患者健康结果的影响

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Abstract

Background/Objectives: Evidence on the optimal components and effectiveness of care programs for patients with multimorbidity is limited. This study aimed to evaluate the impact of a structured interdisciplinary program on the incidence of emergency visits, hospitalizations, and avoidable outpatient consultations following an admission or emergency visit. Methods: This retrospective observational study included 200 patients enrolled in the Multimorbidity Care Program at Hospital Universitario Infanta Cristina. Event rates were compared during the year before and after program inclusion. Multiple-event survival analysis was performed using the counting process method. Results: After program inclusion, patients showed a significant reduction in emergency visits (HR 0.74, 95% CI 0.60-0.92, p = 0.006), in conventional hospitalizations (HR 0.54, 95% CI 0.44-0.68, p = 0.001), and in avoidable outpatient visits (HR 0.66, 95% CI 0.51-0.86, p = 0.005). Conclusions: An interdisciplinary care model for patients over 65 with multimorbidity, integrating comprehensive multidimensional assessment, structured patient education, early management of decompensations in a day hospital, and systematic medication review, significantly reduces healthcare utilization. These findings support implementing integrated care programs for complex patients, though multicenter studies and cost-effectiveness analyses are needed to confirm generalizability and sustainability.

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