Coller Ryan J, Klitzner Thomas S, Saenz Adrianna A, Lerner Carlos F, Nelson Bergen B, Chung Paul J
Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin;
Department of Pediatrics, David Geffen School of Medicine at UCLA.
Pediatrics. 2015 Dec;136(6):e1550-60. doi: 10.1542/peds.2015-1618. Epub 2015 Nov 2.
Despite considerable attention, little is known about the degree to which primary care medical homes influence early postdischarge utilization. We sought to test the hypothesis that patients with medical homes are less likely to have early postdischarge hospital or emergency department (ED) encounters.
This prospective cohort study enrolled randomly selected patients during an acute hospitalization at a children's hospital during 2012 to 2014. Demographic and clinical data were abstracted from administrative sources and caregiver questionnaires on admission through 30 days postdischarge. Medical home experience was assessed by using Maternal and Child Health Bureau definitions. Primary outcomes were 30-day unplanned readmission and 7-day ED visits to any hospital. Logistic regression explored relationships between outcomes and medical home experiences.
We followed 701 patients, 97% with complete data. Thirty-day unplanned readmission and 7-day ED revisit rates were 12.4% and 5.6%, respectively. More than 65% did not have a medical home. In adjusted models, those with medical home component "having a usual source of sick and well care" had fewer readmissions than those without (adjusted odds ratio 0.54, 95% confidence interval 0.30-0.96). Readmissions were higher among those with less parent confidence in avoiding a readmission, subspecialist primary care providers, longer length of index stay, and more hospitalizations in the past year. ED visits were associated with lack of parent confidence but not medical home components.
Lacking a usual source for care was associated with readmissions. Lack of parent confidence was associated with readmissions and ED visits. This information may be used to target interventions or identify high-risk patients before discharge.
尽管受到了广泛关注，但对于初级保健医疗之家对出院后早期医疗利用的影响程度，我们知之甚少。我们试图验证这样一个假设，即拥有医疗之家的患者出院后早期再次入院或前往急诊科就诊的可能性较小。
这项前瞻性队列研究在2012年至2014年期间，于一家儿童医院对随机选取的急性住院患者进行了招募。从行政资料和护理人员入院至出院后30天的问卷调查中提取了人口统计学和临床数据。使用母婴健康局的定义评估医疗之家经历。主要结局为30天内非计划再次入院以及7天内前往任何医院的急诊科就诊。逻辑回归分析探讨了结局与医疗之家经历之间的关系。
我们对701例患者进行了随访，97%的患者有完整数据。30天内非计划再次入院率和7天内急诊科复诊率分别为12.4%和5.6%。超过65%的患者没有医疗之家。在调整模型中，拥有医疗之家组成部分“有常规的患病和健康护理来源”的患者再次入院的情况少于没有该组成部分的患者（调整后的比值比为0.54，95%置信区间为0.30 - 0.96）。在那些家长对避免再次入院信心较低、由专科初级保健提供者诊治、首次住院时间较长以及过去一年住院次数较多的患者中，再次入院率较高。前往急诊科就诊与家长信心不足有关，但与医疗之家的组成部分无关。
缺乏常规的护理来源与再次入院有关。家长信心不足与再次入院和前往急诊科就诊有关。这些信息可用于在出院前针对性地进行干预或识别高危患者。
