Enlow Elizabeth, Passarella Molly, Lorch Scott A
Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
Pediatrics. 2017 Jul;140(1). doi: 10.1542/peds.2017-0339. Epub 2017 Jun 15.
Continuity of care is a key aspect of the patient-centered medical home and improves pediatric outcomes. Health care reform requires high-quality data to demonstrate its continued value. We hypothesized that increased provider continuity in infancy will reduce urgent health care use and increase receipt of preventive services in early childhood.
Continuity, using the Usual Provider of Care measure, was calculated across all primary care encounters during the first year of life in a prospectively-constructed cohort of 17 773 infants receiving primary care from birth through 3 years at 30 clinics. Health care utilization and preventive care outcomes were measured from ages 1 to 3 years. Confounders, including chronic conditions, number of sick visits in the first year, socioeconomic status, and site, were addressed by using multivariable regression models incorporating a propensity score.
Demographics associated with the lowest continuity quartile included white race (adjusted odds ratio [aOR] 1.43; 95% confidence interval [CI] 1.25-1.64), Medicaid insurance (aOR 1.41; 95% CI 1.23-1.61), and asthma (aOR 1.59; 95% CI 1.30-1.93). Lower continuity was associated with more ambulatory care-sensitive hospitalizations (adjusted incidence rate ratio 2.74; 95% CI 1.49-5.03), ambulatory sick visits (adjusted incidence rate ratio 1.08; 95% CI 1.05-1.11), and lower odds of lead screening (aOR 0.61; 95% CI 0.46-0.79). These associations were stronger for children with chronic conditions. Continuity measured during well visits was not associated with outcomes.
Continuity may improve care quality and prevent high-cost health encounters, especially for children with chronic conditions. Novel solutions are needed to improve continuity in the medical home.
连续性医疗是以人为本的医疗之家的关键要素，可改善儿科治疗效果。医疗改革需要高质量数据来证明其持续价值。我们推测，婴儿期医疗服务提供者连续性的提高将减少紧急医疗服务的使用，并增加幼儿期预防性服务的接受率。
在一个前瞻性构建的队列中，对17773名从出生到3岁在30家诊所接受初级保健的婴儿，计算其出生后第一年所有初级保健就诊过程中的连续性（采用常规医疗服务提供者测量法）。从1岁到3岁测量医疗服务利用情况和预防性保健结果。通过使用纳入倾向评分的多变量回归模型，对包括慢性病、第一年就诊次数、社会经济地位和诊所地点等混杂因素进行了处理。
与连续性最低四分位数相关的人口统计学特征包括白人种族（调整后的优势比[aOR]为1.43；95%置信区间[CI]为1.25 - 1.64）、医疗补助保险（aOR为1.41；95%CI为1.23 - 1.61）和哮喘（aOR为1.59；95%CI为1.30 - 1.93）。连续性较低与更多的非卧床护理敏感型住院（调整后的发病率比为2.74；95%CI为1.49 - 5.03）、非卧床就诊（调整后的发病率比为1.08；95%CI为1.05 - 1.11）以及较低的铅筛查几率（aOR为0.61；95%CI为0.46 - 0.79）相关。这些关联在患有慢性病的儿童中更强。在健康检查期间测量的连续性与结果无关。
连续性可能会提高医疗质量并预防高成本的医疗遭遇，特别是对于患有慢性病的儿童。需要新的解决方案来提高医疗之家中的连续性。
