骨科门诊治疗是否会减少全关节置换术后急诊就诊的利用？
Does Orthopaedic Outpatient Care Reduce Emergency Department Utilization After Total Joint Arthroplasty?
机构信息
M. A. Chaudhary, J. K. Lange, L. M. Pak, J. A. Blucher, L. B. Barton, D. J. Sturgeon, A. H. Haider, A. J. Schoenfeld, Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA T. Koehlmoos, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
出版信息
Clin Orthop Relat Res. 2018 Aug;476(8):1655-1662. doi: 10.1097/01.blo.0000533620.66105.ef.
BACKGROUND
Emergency department (ED) visits after elective surgical procedures are a potential target for interventions to reduce healthcare costs. More than 1 million total joint arthroplasties (TJAs) are performed each year with postsurgical ED utilization estimated in the range of 10%.
QUESTIONS/PURPOSES: We asked whether (1) outpatient orthopaedic care was associated with reduced ED utilization and (2) whether there were identifiable factors associated with ED utilization within the first 30 and 90 days after TJA.
METHODS
An analysis of adult TRICARE beneficiaries who underwent TJA (2006-2014) was performed. TRICARE is the insurance program of the Department of Defense, covering > 9 million beneficiaries. ED use within 90 days of surgery was the primary outcome and postoperative outpatient orthopaedic care the primary explanatory variable. Patient demographics (age, sex, race, beneficiary category), clinical characteristics (length of hospital stay, prior comorbidities, complications), and environment of care were used as covariates. Logistic regression adjusted for all covariates was performed to determine factors associated with ED use.
RESULTS
We found that orthopaedic outpatient care (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.68-0.77) was associated with lower odds of ED use within 90 days. We also found that index hospital length of stay (OR, 1.07; 95% CI, 1.04-1.10), medical comorbidities (OR, 1.16; 95% CI, 1.08-1.24), and complications (OR, 2.47; 95% CI, 2.24-2.72) were associated with higher odds of ED use.
CONCLUSIONS
When considering that at 90 days, only 3928 patients sustained a complication, a substantial number of ED visits (11,486 of 15,414 [75%]) after TJA may be avoidable. Enhancing access to appropriate outpatient care with improved discharge planning may reduce ED use after TJA. Further research should be directed toward unpacking the situations, outside of complications, that drive patients to access the ED and devise interventions that could mitigate such behavior.
LEVEL OF EVIDENCE
Level III, therapeutic study.
背景
择期手术后急诊部（ED）就诊是降低医疗成本的潜在目标。每年进行超过 100 万例全关节置换术（TJA），术后 ED 使用率估计在 10%左右。
问题/目的：我们想知道（1）门诊骨科护理是否与降低 ED 使用率相关，以及（2）在 TJA 后 30 天和 90 天内，是否存在与 ED 使用率相关的可识别因素。
方法
对 2006-2014 年接受 TJA 的成人 TRICARE 受益人的分析。TRICARE 是国防部的保险计划，覆盖超过 900 万受益人。手术 90 天内的 ED 使用是主要结果，术后门诊骨科护理是主要解释变量。患者人口统计学特征（年龄、性别、种族、受益人类别）、临床特征（住院时间、既往合并症、并发症）和护理环境作为协变量。进行调整所有协变量的逻辑回归，以确定与 ED 使用相关的因素。
结果
我们发现，骨科门诊护理（比值比 [OR]，0.73；95%置信区间 [CI]，0.68-0.77）与 90 天内 ED 使用的可能性降低相关。我们还发现，指数住院时间（OR，1.07；95% CI，1.04-1.10）、医疗合并症（OR，1.16；95% CI，1.08-1.24）和并发症（OR，2.47；95% CI，2.24-2.72）与 ED 使用的可能性增加相关。
结论
考虑到在 90 天时只有 3928 名患者发生并发症，TJA 后大量的 ED 就诊（15414 例中的 11486 例[75%]）可能是可以避免的。通过改善出院计划，增加对适当门诊护理的获取，可能会降低 TJA 后的 ED 使用。应进一步研究，以阐明除并发症之外，导致患者使用 ED 的情况，并制定可以减轻这种行为的干预措施。
证据水平
III 级，治疗性研究。
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