Department of General Practice and Primary Health Care, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
Health Systems Section, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
BMC Fam Pract. 2020 Oct 24;21(1):217. doi: 10.1186/s12875-020-01285-9.
Reducing ambulatory sensitive hospitalisations (ASHs) is a strategy to control spending on hospital care and to improve quality of primary health care. This research investigated whether ASH rates in older people varied by GP and practice characteristics.
We identified ASHs from the national dataset of hospital events for 3755 community-dwelling participants aged 75+ enrolled in a cluster randomised controlled trial involving 60 randomly selected general practices in three regions in New Zealand. Poisson mixed models of 36-month ASH rates were fitted for the entire sample, for complex participants, and non-complex participants. We examined variation in ASH rates according to GP- and practice-level characteristics after adjusting for patient-level predictors of ASH.
Lower rates of ASHs were observed in female GPs (IRR 0.83, CI 0.71 to 0.98). In non-complex participants, but not complex participants, practices in more deprived areas had lower ASH rates (4% lower per deprivation decile higher, IRR 0.96, CI 0.92 to 1.00), whereas main urban centre practices had higher rates (IRR 1.84, CI 1.15 to 2.96). Variance explained by these significant factors was small (0.4% of total variance for GP sex, 0.2% for deprivation, and 0.5% for area type). None of the modifiable practice-level characteristics such as home visiting and systematically contacting patients were significantly associated with ASH rates.
Only a few GP and non-modifiable practice characteristics were associated with variation in ASH rates in 60 New Zealand practices interested in a trial about care of older people. Where there were significant associations, the contribution to overall variance was minimal. It also remains unclear whether lower ASH rates in older people represents underservicing or less overuse of hospital services, particularly for the relatively well patient attending practices in less central, more disadvantaged communities. Thus, reducing ASHs through primary care redesign for older people should be approached carefully.
Australian and New Zealand Clinical Trials Register ACTRN12609000648224 .
减少门诊敏感住院（ASHs）是控制医院护理支出和提高初级卫生保健质量的一种策略。本研究调查了老年人的 ASH 率是否因全科医生和实践特征而异。
我们从全国医院事件数据集识别了 3755 名居住在社区的 75 岁以上参与者的 ASH，这些参与者参加了一项涉及新西兰三个地区的 60 个随机选择的普通实践的集群随机对照试验。我们为整个样本、复杂参与者和非复杂参与者拟合了 36 个月 ASH 率的泊松混合模型。在调整了 ASH 的患者预测因素后，我们根据全科医生和实践水平特征检查了 ASH 率的变化。
女性全科医生的 ASH 率较低（IRR 0.83，CI 0.71 至 0.98）。在非复杂参与者中，但在复杂参与者中并非如此，较贫困地区的实践具有较低的 ASH 率（每剥夺十分之一低 4%，IRR 0.96，CI 0.92 至 1.00），而主要城市中心的实践具有较高的 ASH 率（IRR 1.84，CI 1.15 至 2.96）。这些显著因素解释的方差很小（全科医生性别占总方差的 0.4%，贫困占 0.2%，区域类型占 0.5%）。没有一个可修改的实践水平特征（如家访和系统联系患者）与 ASH 率显著相关。
在 60 家对老年人护理试验感兴趣的新西兰实践中，只有少数全科医生和不可修改的实践特征与 ASH 率的变化相关。在存在显著关联的情况下，对总方差的贡献最小。尚不清楚老年人较低的 ASH 率是否代表服务不足或过度使用医院服务的减少，特别是对于在较不中心、较不利社区就诊的相对健康的患者。因此，应谨慎通过老年人初级保健设计的改变来减少 ASH。
澳大利亚和新西兰临床试验注册 ACTRN12609000648224 。
