Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States.
Robert Wood Johnson Clinical Scholars Program, Yale School of Medicine, New Haven, CT, United States.
Am J Emerg Med. 2018 May;36(5):854-858. doi: 10.1016/j.ajem.2018.01.070. Epub 2018 Feb 4.
Patients newly insured through coverage expansion under the Affordable Care Act (ACA) may have difficulty obtaining timely primary care follow-up appointments after emergency department (ED) discharge. We evaluated the association between availability of timely follow-up appointment with practice access improvements, including patient-centered medical home (PCMH) designations or extended-hours appointments.
We performed a secret-shopper audit of primary care practices in greater New Haven, Connecticut. Two callers, posing as patients discharged from the ED, called these practices requesting follow-up appointments. They followed standardized scripts varying in ED diagnosis (uncontrolled hypertension, acute back pain) and insurance status (commercial, exchange, Medicaid). We linked our findings with data from a previously completed survey that assessed practice characteristics and examined the associations between appointment availability and practice access improvements.
Of the 58 included primary care practices, 49 (84.5%) completed both the audit and the survey. Overall, 167/536 calls (31.2%) obtained an appointment in 7days. Practices with PCMH designation were less likely to offer appointments within 7days (23.4% vs. 33.1%, p=0.03). However, callers were more likely to obtain an appointment in 7days from practices offering after-hour appointments (36.3% vs. 27.8%, p=0.04). After adjusting for insurance type, there were no significant associations between practice improvements and 7-day appointment availability or appointment wait time.
PCMH designation and extended-hours appointments were not associated with improved availability of timely primary care follow-up appointment for discharged ED patients. EDs should engage local clinicians and other stakeholders to strengthen linkage and care transition with outpatient practices.
通过平价医疗法案（ACA）扩大覆盖范围新获得保险的患者在从急诊（ED）出院后可能难以获得及时的初级保健随访预约。我们评估了及时获得随访预约与实践准入改善之间的关联，包括以患者为中心的医疗之家（PCMH）指定或延长就诊时间。
我们对康涅狄格州纽黑文市进行了初级保健实践的秘密购物者审计。两名打电话的人，冒充从 ED 出院的患者，向这些实践打电话要求预约随访。他们遵循了标准化的脚本，这些脚本在 ED 诊断（未控制的高血压、急性背痛）和保险状况（商业、交易所、医疗补助）方面有所不同。我们将我们的发现与之前完成的一项调查数据相关联，该调查评估了实践特征，并检查了预约可用性与实践准入改善之间的关联。
在纳入的 58 家初级保健实践中，有 49 家（84.5%）同时完成了审计和调查。总体而言，536 次通话中有 167 次（31.2%）在 7 天内预约。具有 PCMH 指定的实践提供 7 天内预约的可能性较低（23.4%对 33.1%，p=0.03）。然而，拨打者在提供下班时间预约的实践中更有可能在 7 天内获得预约（36.3%对 27.8%，p=0.04）。在调整了保险类型后，实践改进与 7 天预约可用性或预约等待时间之间没有显著关联。
PCMH 指定和延长就诊时间与改善 ED 出院患者及时获得初级保健随访预约的可用性无关。ED 应与当地临床医生和其他利益相关者合作，加强与门诊实践的联系和护理过渡。
