Regional Health System Office, National University Health System, Singapore, Singapore
Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.
BMJ Open. 2019 Dec 31;9(12):e030718. doi: 10.1136/bmjopen-2019-030718.
Stable patients with chronic conditions could be appropriately cared for at family medicine clinics (FMC) and discharged from hospital specialist outpatient clinics (SOCs). The Right-Site Care Programme with Frontier FMC emphasised care organised around patients in community rather than hospital-based providers, with one identifiable primary provider. This study evaluated impact of this programme on mortality and healthcare utilisation.
A retrospective study without randomisation using secondary data analysis of patients enrolled in the intervention matched 1:1 with unenrolled patients as controls.
Programme was supported by the Ministry of Health in Singapore, a city-state nation in Southeast Asia with 5.6 million population.
Intervention group comprises patients enrolled from January to December 2014 (n=684) and control patients (n=684) with at least one SOC and no FMC attendance during same period.
Family physician in Frontier FMC managed patients in consultation with relevant specialist physicians or fully managed patients independently. Care teams in SOCs and FMC used a common electronic medical records system to facilitate care coordination and conducted regular multidisciplinary case conferences.
Deidentified linked healthcare administrative data for time period of January 2011 to December 2017 were extracted. Three-year postenrolment mortality rates and utilisation frequencies and charges for SOC, public primary care centres (polyclinic), emergency department attendances and emergency, non-day surgery inpatient and all-cause admissions were compared.
Intervention patients had lower mortality rate (HR=0.37, p<0.01). Among those with potential of postenrolment polyclinic attendance, intervention patients had lower frequencies (incidence rate ratio (IRR)=0.60, p<0.01) and charges (mean ratio (MR)=0.51, p<0.01). Among those with potential of postenrolment SOC attendance, intervention patients had higher frequencies (IRR=2.06, p<0.01) and charges (MR=1.86, p<0.01).
Intervention patients had better survival, probably because their chronic conditions were better managed with close monitoring, contributing to higher total outpatient attendance frequencies and charges.
稳定的慢性病患者可以在家庭医学诊所（FMC）得到适当的照顾，并从医院专科门诊（SOC）出院。以社区而非医院为基础的提供者为中心的 Frontier FMC 的正确护理计划强调了以患者为中心的护理，只有一个可识别的主要提供者。本研究评估了该计划对死亡率和医疗保健利用的影响。
这是一项没有随机分组的回顾性研究，使用二级数据分析对参加干预计划的患者进行分析，将干预组患者与同期未参加干预计划的患者进行 1:1 匹配作为对照组。
该计划得到了新加坡卫生部的支持，新加坡是一个位于东南亚的城市国家，人口为 560 万。
干预组包括 2014 年 1 月至 12 月期间登记的患者（n=684）和对照组患者（n=684），这些患者至少有一次 SOC 就诊，且在此期间没有 FMC 就诊。
Frontier FMC 的家庭医生在与相关专科医生协商的情况下管理患者，或独立管理患者。SOC 和 FMC 的护理团队使用共同的电子病历系统来促进护理协调，并定期进行多学科病例会议。
提取 2011 年 1 月至 2017 年期间的去识别链接医疗保健管理数据。比较 3 年后的死亡率以及 SOC、公共初级保健中心（综合诊疗所）、急诊就诊和急诊、非日间手术住院和全因入院的就诊频率和费用。
干预组的死亡率较低（HR=0.37，p<0.01）。在有潜在 FMC 就诊可能的患者中，干预组的就诊频率较低（发病率比（IRR）=0.60，p<0.01），费用也较低（均值比（MR）=0.51，p<0.01）。在有潜在 SOC 就诊可能的患者中，干预组的就诊频率较高（IRR=2.06，p<0.01），费用也较高（MR=1.86，p<0.01）。
干预组患者的生存率更高，这可能是因为他们的慢性病得到了更好的管理，通过密切监测，提高了总门诊就诊频率和费用。
