Division of Emergency Medicine, Washington University, St. Louis, MO, USA.
Acad Emerg Med. 2010 Jan;17(1):55-62. doi: 10.1111/j.1553-2712.2009.00621.x.
Determine if 1) proximity of referral to a federally qualified health center (FQHC) improves initial follow-up rates for discharged emergency patients, 2) improved initial follow-up rates are associated with improved rates for an "ongoing relationship" with the FQHC, and 3) an ongoing relationship with an FQHC is associated with decreased subsequent emergency department (ED) utilization over a 2-year follow-up period.
An expedited referral system was initiated just prior to January 2004 for discharged ED patients referred to an FQHC. Referral categories were as follows: R1 = next-day; R2 = 2 to 7 days; R3 = 2 to 3 weeks; and R4 = follow-up as needed. The FQHC database for 2004-2006 was merged with the ED database from 2004 through 2006. The FQHC database contained all ED referrals, the referral category, whether the patient kept his or her initial ED referral appointment, all subsequent scheduled clinic appointments, and whether the patient kept any of the subsequent scheduled appointments. We compared initial referral follow-up rates and subsequent scheduled visits to the FQHC for each referral category, over a 2-year follow-up period. We evaluated the effects of age, sex, marital status, insurance status, initial triage score, race, comorbidities, and number of prescription medications on initial follow-up, and subsequent kept appointments with the FQHC. We defined an "ongoing relationship" as one or more kept scheduled appointments annually. Finally, we compared the number of subsequent ED visits over the follow-up period between patients who maintained an ongoing relationship with the FQHC and those who did not, before and after correcting for the demographic and clinical factors.
There were 520 referrals over the study period. Follow-up rates ranged from 37.5% (95% confidence interval [CI] = 13.5% to 69.6%) for R1 to 9.0% (95% CI = 4.4% to 17.0%) for R4. The overall ongoing relationship rate was 7.1% (95% CI = 5.2% to 9.7%) and had weak association with temporal proximity of referral. On bivariate analysis, older age, female sex, white race, one or more comorbidities, and three or more medications were associated with increased rates of initial follow-up. These factors (with the exception of race) were also associated with increased rates of developing an ongoing relationship. Patients with an ongoing relationship with the FQHC had more repeat ED visits over the study period than did patients without (3.6 vs. 1.7, p = 0.003). However, this difference was no longer evident after adjusting for age, race, comorbidities, and medication usage.
Overall patient follow-up to an FQHC was low, but increased with next-day or same-week referral. The ongoing relationship rate was low, but increased with temporal proximity of ED referral. Increased comorbidities and medication usage were significantly associated with increased initial follow-up rates, development of an ongoing relationship, and subsequent ED utilization. Patients with an ongoing relationship with the FQHC had higher ED utilization over the 2-year follow-up period, likely due to a higher rate of comorbidities.
确定 1）向合格的联邦健康中心（FQHC）转诊的接近程度是否会提高出院急诊患者的初始随访率，2）提高初始随访率是否与与 FQHC 建立“持续关系”的比例增加有关，以及 3）与 FQHC 建立持续关系是否与在 2 年随访期间随后急诊部门（ED）就诊率降低有关。
在 2004 年 1 月之前，为转诊至 FQHC 的出院 ED 患者启动了加速转诊系统。转诊类别如下：R1=次日；R2=2 至 7 天；R3=2 至 3 周；R4=按需随访。将 2004-2006 年的 FQHC 数据库与 2004 年至 2006 年的 ED 数据库合并。FQHC 数据库包含所有 ED 转诊、转诊类别、患者是否遵守其初始 ED 转诊预约、所有后续预约的门诊预约，以及患者是否遵守任何后续预约。我们比较了每个转诊类别的初始转诊随访率和随后到 FQHC 的预约，随访期为 2 年。我们评估了年龄、性别、婚姻状况、保险状况、初始分诊评分、种族、合并症和处方药物数量对初始随访以及随后与 FQHC 的预约保留的影响。我们将“持续关系”定义为每年保留一次或多次预约。最后，我们比较了在随访期间保持与 FQHC 持续关系的患者和未保持持续关系的患者的后续 ED 就诊次数，在对人口统计学和临床因素进行校正之前和之后。
在研究期间共有 520 次转诊。随访率从 R1 的 37.5%（95%置信区间[CI]=13.5%至 69.6%）到 R4 的 9.0%（95%CI=4.4%至 17.0%）不等。总体持续关系率为 7.1%（95%CI=5.2%至 9.7%），与转诊时间的接近程度呈弱相关。在单变量分析中，年龄较大、女性、白人种族、一种或多种合并症以及三种或更多药物与初始随访率增加有关。这些因素（种族除外）也与建立持续关系的比例增加有关。与没有 FQHC 持续关系的患者相比，有 FQHC 持续关系的患者在研究期间有更多的重复 ED 就诊（3.6 次比 1.7 次，p=0.003）。然而，在调整年龄、种族、合并症和药物使用后，这种差异不再明显。
总体而言，患者对 FQHC 的随访率较低，但与次日或同一周的转诊相比有所增加。持续关系率较低，但与 ED 转诊的时间接近程度呈正相关。合并症和药物使用增加与初始随访率增加、建立持续关系以及随后的 ED 就诊率增加显著相关。与 FQHC 保持持续关系的患者在 2 年随访期间 ED 就诊率更高，可能是由于合并症的发生率较高。
