Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass.
Am J Med. 2013 Nov;126(11):1016.e9-15. doi: 10.1016/j.amjmed.2013.03.025. Epub 2013 Aug 29.
Limited primary care access and care discontinuities hamper care for patients following hospital discharge. As the proportion of inpatient care delivered by hospitalists continues to increase, hybrid models that incorporate hospitalists in post-discharge care may ameliorate this problem.
We established a post-discharge clinic staffed by hospitalists in a large academic urban primary care practice in October 2009. We compared visits of recently hospitalized patients seen in the post-discharge clinic with post-discharge visits elsewhere in the practice, including patient demographics, health care utilization, and duration from discharge, using generalized estimating equations to account for repeated hospitalizations.
Patients seen in the post-discharge clinic and elsewhere in the practice were generally similar, although patients seen in the post-discharge clinic were particularly likely to be black and receive primary care from residents. Relative to other patients seen following discharge, patients in the post-discharge clinic were seen 8.45 ± 0.43 days earlier (P <.001). Among all 10,845 discharges of Healthcare Associates patients between 2009 and 2011, patients were 40% more likely to be seen within a week of discharge when the post-discharge clinic was open than when it was closed (adjusted odds ratio 1.41; 95% confidence interval, 1.25-1.57).
In this primary care practice, a hospitalist-staffed post-discharge clinic was associated with substantially shorter time to first post-hospitalization visit and with improvement in the overall likelihood of an early visit among all hospitalized patients. It was particularly used by black patients and those seen by residents, in whom access tends to be most fragmented, and may represent a novel approach to the problem of post-discharge care.
有限的初级保健机会和护理不连续阻碍了患者出院后的护理。随着由医院医师提供的住院治疗比例不断增加，将医院医师纳入出院后护理的混合模式可能会改善这一问题。
我们于 2009 年 10 月在一家大型学术城市初级保健实践中设立了由医院医师负责的出院后诊所。我们使用广义估计方程来比较最近住院患者在出院后诊所就诊与在实践中其他地方就诊的就诊情况，包括患者人口统计学、医疗保健利用情况以及从出院到就诊的时间，以考虑到多次住院的情况。
在出院后诊所和实践中其他地方就诊的患者通常相似，尽管在出院后诊所就诊的患者特别可能是黑人并接受住院医师的初级保健。与其他出院后就诊的患者相比，在出院后诊所就诊的患者提前 8.45±0.43 天就诊（P<0.001）。在 2009 年至 2011 年间 Healthcare Associates 患者的所有 10845 次出院中，当出院后诊所开放时，患者在出院后一周内就诊的可能性增加了 40%（调整后的优势比为 1.41；95%置信区间，1.25-1.57）。
在这家初级保健实践中，由医院医师负责的出院后诊所与首次出院后就诊的时间显著缩短相关，并且与所有住院患者尽早就诊的总体可能性提高相关。它特别为黑人患者和由住院医师接诊的患者使用，这些患者的就诊机会往往最分散，并且可能代表了一种解决出院后护理问题的新方法。
