医疗碎片化与急性冠脉事件：队列研究。
Healthcare Fragmentation and Incident Acute Coronary Heart Disease Events: a Cohort Study.
机构信息
Weill Cornell Medicine , New York, NY, USA.
University of Alabama at Birmingham, Birmingham, AL, USA.
出版信息
J Gen Intern Med. 2021 Feb;36(2):422-429. doi: 10.1007/s11606-020-06305-z. Epub 2020 Nov 2.
BACKGROUND
Highly fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with excess tests, procedures, emergency department visits, and hospitalizations. Whether fragmented care is associated with worse health outcomes, or whether any association varies with health status, is unclear.
OBJECTIVE
To determine whether fragmented care is associated with the risk of incident coronary heart disease (CHD) events, overall and stratified by self-rated general health.
DESIGN AND PARTICIPANTS
We conducted a secondary analysis of the nationwide prospective Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study (2003-2016). We included participants who were ≥ 65 years old, had linked Medicare fee-for-service claims, and had no history of CHD (N = 10,556).
MAIN MEASURES
We measured fragmentation with the reversed Bice-Boxerman Index. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and adjudicated incident CHD events in the 3 months following each exposure period.
KEY RESULTS
The mean age was 70 years; 57% were women, and 34% were African-American. Over 11.8 years of follow-up, 569 participants had CHD events. Overall, the adjusted hazard ratio (HR) for the association between high fragmentation and incident CHD events was 1.14 (95% confidence interval (CI) 0.92, 1.39). Among those with very good or good self-rated health, high fragmentation was associated with an increased hazard of CHD events (adjusted HR 1.35; 95% CI 1.06, 1.73; p = 0.01). Among those with fair or poor self-rated health, high fragmentation was associated with a trend toward a decreased hazard of CHD events (adjusted HR 0.54; 95% CI 0.29, 1.01; p = 0.052). There was no association among those with excellent self-rated health.
CONCLUSION
High fragmentation was associated with an increased independent risk of incident CHD events among those with very good or good self-rated health.
背景
门诊护理高度碎片化（即护理分散在多个提供者之间，没有主导提供者）与过度检查、手术、急诊就诊和住院有关。碎片化护理是否与更差的健康结果相关，或者任何关联是否因健康状况而异，目前尚不清楚。
目的
确定碎片化护理是否与新发冠心病（CHD）事件的风险相关，整体情况以及按自我报告的一般健康状况分层的情况。
设计和参与者
我们对全国范围的前瞻性地理和种族差异导致中风原因（REGARDS）队列研究（2003-2016 年）进行了二次分析。我们纳入了≥65 岁、有医疗保险费用报销记录且无 CHD 病史的参与者（N=10556）。
主要测量指标
我们使用反向 Bice-Boxerman 指数来衡量碎片化程度。我们使用 Cox 比例风险模型来确定随着时间变化的暴露情况与暴露期后 3 个月内经裁决的新发 CHD 事件之间的关联。
主要结果
平均年龄为 70 岁；57%为女性，34%为非裔美国人。在 11.8 年的随访期间，有 569 名参与者发生了 CHD 事件。总体而言，高碎片化与新发 CHD 事件之间的调整后的风险比（HR）为 1.14（95%置信区间[CI]，0.92，1.39）。在自我报告健康状况非常好或好的人群中，高碎片化与 CHD 事件的发生风险增加相关（调整后的 HR 为 1.35；95%CI，1.06，1.73；p=0.01）。在自我报告健康状况一般或差的人群中，高碎片化与 CHD 事件发生风险呈下降趋势相关（调整后的 HR 为 0.54；95%CI，0.29，1.01；p=0.052）。在自我报告健康状况极好的人群中，没有相关性。
结论
在自我报告健康状况非常好或好的人群中，高碎片化与新发 CHD 事件的独立风险增加相关。
Zotero 插件