Felder-Heim Caitlin, Mader Kari
Family Medicine, University of California San Francisco, San Francisco, USA.
Family Medicine, University of Colorado School of Medicine, Aurora, USA.
Cureus. 2020 Aug 3;12(8):e9539. doi: 10.7759/cureus.9539.
Introduction Student-Run Free Clinics (SRFCs) are part of the safety-net healthcare system. Given variable settings and models, relatively little is known about the quality of care in these settings. Methods A mixed-methods evaluation of diabetes and hypertension management was conducted for patients initiating care from March 1, 2015, to September 31, 2016, at the DAWN (Dedicated to Aurora's Wellness and Needs) SRFC. Retrospective chart review assessed whether patients received recommended screening tests (process outcomes) and achieved disease control (short-term outcomes). These outcomes were compared to a local community health center (CHC), a local federally qualified health center (FQHC) network, and Colorado Medicaid (CoM) using one proportion t-tests. In-depth case studies of randomly selected individuals with good and poor disease control identified targets for quality improvement through nominal group technique. Results Diabetic patients (n=30) were recommended screening, including HbA1c (93.3%) (vs. 77.8% with CoM, p=0.04), nephropathy care (70%) (vs. 85.4% with CoM, p=0.02), retinopathy examination (30%) (vs. 40.47% with CoM, p=0.24). Diabetic short-term outcomes showed 46.6% with poor control (vs. 61.1% at the CHC, p=0.10; vs. 30.62% at the FQHC, p=0.06; vs. 55% with CoM, p=0.10). Patients with hypertension (n=75) 33.3% had controlled (<140/90) blood pressure (vs. 49.2% at the CHC, p<0.01; vs. 61.1% at the FQHC, p<0.01; vs. 58.9% with CoM, p<0.01). Themes for quality improvement included improving follow-up, documentation and data collection, clinic processes, and addressing barriers to care. Discussion DAWN outcomes were comparable to other safety-net providers for diabetes, similar to findings in evaluations conducted by other SRFCs. However, DAWN did not have equivalent outcomes for hypertension in contrast to other published findings from SRFCs. Poor access to care and baseline chronic disease control among DAWN patients may have contributed to these findings. Conclusions While this study is not directly generalizable to all SRFC models and communities, these results contribute to the growing body of data around SRFCs and chronic disease management and indicate that SRFCs may have a role in the safety-net healthcare system. However, more study is needed to ensure that SRFCs can provide high-quality care because otherwise efforts should focus on other strategies to expand access within the safety-net system.
引言 学生运营的免费诊所（SRFCs）是安全网医疗系统的一部分。鉴于其设置和模式各不相同，人们对这些环境下的医疗质量了解相对较少。方法 对2015年3月1日至2016年9月31日在DAWN（致力于奥罗拉的健康与需求）SRFC开始接受治疗的患者进行了糖尿病和高血压管理的混合方法评估。回顾性病历审查评估患者是否接受了推荐的筛查测试（过程结果）并实现了疾病控制（短期结果）。使用单比例t检验将这些结果与当地社区卫生中心（CHC）、当地联邦合格健康中心（FQHC）网络和科罗拉多医疗补助（CoM）进行比较。通过名义小组技术，对随机选择的疾病控制良好和不佳的个体进行深入案例研究，确定质量改进目标。结果 糖尿病患者（n = 30）被推荐进行筛查，包括糖化血红蛋白（HbA1c）（93.3%）（与CoM的77.8%相比，p = 0.04）、肾病护理（70%）（与CoM的85.4%相比，p = 0.02）、视网膜病变检查（30%）（与CoM的40.47%相比，p = 0.24）。糖尿病短期结果显示，46.6%的患者控制不佳（与CHC的61.1%相比，p = 0.10；与FQHC的30.62%相比，p = 0.06；与CoM的55%相比，p = 0.10）。高血压患者（n = 75）中，33.3%的患者血压得到控制（<140/90）（与CHC的49.2%相比，p<0.01；与FQHC的61.1%相比，p<0.01；与CoM的58.9%相比，p<0.01）。质量改进的主题包括改善随访、记录和数据收集、诊所流程以及解决护理障碍。讨论 DAWN的结果在糖尿病方面与其他安全网提供者相当，与其他SRFCs进行的评估结果相似。然而，与SRFCs其他已发表的结果相比，DAWN在高血压方面的结果并不相同。DAWN患者获得护理的机会不佳以及基线慢性病控制情况可能导致了这些结果。结论 虽然这项研究不能直接推广到所有SRFC模式和社区，但这些结果为围绕SRFCs和慢性病管理的不断增长的数据做出了贡献，并表明SRFCs可能在安全网医疗系统中发挥作用。然而，需要更多的研究来确保SRFCs能够提供高质量的护理，否则应将努力重点放在安全网系统内扩大获得护理机会的其他策略上。
