Department of Family and Community Medicine and the Centre for Urban Health Solutions in the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
Ann Fam Med. 2018 Sep;16(5):419-427. doi: 10.1370/afm.2291.
Compared with other high-income countries, Canada and the United States have among the highest rates of emergency department use and the lowest rates of primary care physicians reporting arrangements for after-hours care. We assessed whether enrollment in a medical home mandated to provide after-hours care in Ontario, Canada, was associated with reduced emergency department use.
We conducted a retrospective cohort study using linked administrative data. We included all adult Ontarians enrolled in a medical home between April 1, 2005, and March 31, 2012, who had a minimum of 3 years of outcome data before and after enrollment (N = 2,945,087). We performed a linear segmented analysis with patient-level data to understand the association between initial enrollment in a medical home and emergency department visits, the proportion of all primary care visits occurring on the weekend, and the primary care visit rate. Age, income quintile, comorbidity, and morbidity were included in the modeling as time-varying covariates and sex as a stable variable.
The emergency department visit rate increased by 0.8% (95% CI, 0.7% to 0.9%) per year before medical home enrollment and by 1.5% (95% CI, 1.4% to 1.5%) per year after the transition. Enrollment in a medical home was associated with an increase in the proportion of visits that occurred on weekends, but a decrease in the overall primary care visit rate.
Enrollment of adult Ontarians in a primary care medical home offering after-hours care was not associated with a reduction in emergency department use. It will therefore be important to prospectively evaluate policy reforms aimed at improving access to primary care outside of conventional hours.
与其他高收入国家相比，加拿大和美国的急诊就诊率最高，而提供夜间医疗服务的初级保健医生比例最低。我们评估了安大略省强制实施家庭医生提供夜间医疗服务后，是否会降低急诊就诊率。
我们使用链接的行政数据进行了回顾性队列研究。我们纳入了 2005 年 4 月 1 日至 2012 年 3 月 31 日期间在安大略省家庭医生处注册的所有成年患者（n=2945087），这些患者在注册前后至少有 3 年的结果数据。我们对患者水平数据进行了线性分段分析，以了解最初注册家庭医生与急诊就诊、周末所有初级保健就诊的比例和初级保健就诊率之间的关联。模型中纳入了年龄、收入五分位数、合并症和发病率作为随时间变化的协变量，以及性别作为稳定变量。
在注册家庭医生之前，急诊就诊率每年增加 0.8%（95%置信区间，0.7%至 0.9%），而在过渡后每年增加 1.5%（95%置信区间，1.4%至 1.5%）。注册家庭医生与周末就诊比例增加有关，但与整体初级保健就诊率下降有关。
安大略省成年患者注册家庭医生接受夜间医疗服务与急诊就诊率降低无关。因此，前瞻性评估旨在改善常规时间之外获得初级保健服务的政策改革将非常重要。
