CMAJ. 2013 Oct 1;185(14):E681-9. doi: 10.1503/cmaj.130048. Epub 2013 Aug 19.
Early physician follow-up after discharge is associated with lower rates of death and readmission among patients with heart failure. We explored whether physician continuity further influences outcomes after discharge.
We used data from linked administrative databases for all adults aged 20 years or more in the province of Alberta who were discharged alive from hospital between January 1999 and June 2009 with a first-time diagnosis of heart failure. We used Cox proportional hazard models with time-dependent covariates to analyze the effect of follow-up with a familiar physician within the first month after discharge on the primary outcome of death or urgent all-cause readmission over 6 months. A familiar physician was defined as one who had seen the patient at least twice in the year before the index admission or once during the index admission.
In the first month after discharge, 5336 (21.9%) of the 24 373 identified patients had no follow-up visits, 16 855 (69.2%) saw a familiar physician, and 2182 (9.0%) saw unfamiliar physician(s) exclusively. The risk of death or unplanned readmission during the 6-month observation period was lower among patients who saw a familiar physician (43.6%; adjusted hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.83-0.91) or an unfamiliar physician (43.6%; adjusted HR 0.90, 95% CI 0.83-0.97) for early follow-up visits, as compared with patients who had no follow-up visits (62.9%). Taking into account all follow-up visits over the 6-month period, we found that the risk of death or urgent readmission was lower among patients who had all of their visits with a familiar physician than among those followed by unfamiliar physicians (adjusted HR 0.91, 95% CI 0.85-0.98).
Early physician follow-up after discharge and physician continuity were both associated with better outcomes among patients with heart failure. Research is needed to explore whether physician continuity is important for other conditions and in settings other than recent hospital discharge.
心力衰竭患者出院后早期与医生随访可降低死亡率和再入院率。我们探讨了医生的连续性是否会对出院后的结果产生进一步的影响。
我们使用来自艾伯塔省行政数据库的链接数据，这些数据来自于 1999 年 1 月至 2009 年 6 月期间首次被诊断为心力衰竭且在出院时存活的 20 岁及以上的所有成年人。我们使用具有时间依赖性协变量的 Cox 比例风险模型来分析出院后一个月内与熟悉的医生进行随访对 6 个月内死亡或紧急全因再入院的主要结局的影响。熟悉的医生定义为在指数入院前一年至少见过患者两次或在指数入院期间见过一次的医生。
在出院后的第一个月，24373 名患者中有 5336 名（21.9%）没有随访，16855 名（69.2%）看到了熟悉的医生，2182 名（9.0%）只看到了不熟悉的医生。在 6 个月的观察期内，与未随访的患者相比，看到熟悉医生（43.6%；调整后的危险比 [HR]0.87，95%置信区间 [CI]0.83-0.91）或不熟悉医生（43.6%；调整后的 HR 0.90，95% CI 0.83-0.97）的患者死亡或无计划再入院的风险较低。考虑到 6 个月期间的所有随访，我们发现与接受不熟悉医生随访的患者相比，所有就诊均由熟悉医生进行的患者死亡或紧急再入院的风险较低（调整后的 HR 0.91，95% CI 0.85-0.98）。
出院后早期与医生随访和医生的连续性都与心力衰竭患者的更好结局相关。需要研究医生的连续性是否对其他疾病以及除最近出院之外的其他环境重要。
