Harvard Medical School, Boston, MA, USA.
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
J Gen Intern Med. 2022 Feb;37(3):548-555. doi: 10.1007/s11606-021-06793-7. Epub 2021 May 4.
The relationship between clinician and patient is the cornerstone of primary care. Breakdown and termination of this relationship are understudied yet important, undesirable outcomes.
To better understand the nature and extent of provider and clinic termination of the primary care relationship.
Retrospective observational case-control study.
Adult patients in Eastern Massachusetts who received primary care at hospital- and community-based clinics and health centers participating in a practice-based research network between January 2013 and June 2017.
Formal termination by primary care physician (PCP), reasons for termination, independent predictors of termination based on mixed-effects logistic regression, and documentation of a new PCP after termination.
We identified 158,192 patients who received primary care from 182 PCPs across 16 clinics. We found 536 cases of formal termination. Clinics ranged from 4 to 119 terminations per 10,000 patients (intraclass correlation coefficient [ICC]=0.21; 95% CI: 0.18-0.24). Patient age, race/ethnicity, educational attainment, relationship status, employment status, and insurance type were independent predictors of termination (e.g., compared to patients employed full-time, patients unemployed due to disability were more likely to be terminated [adjusted OR:9.26; 95% CI: 6.74-12.74]). The most common cause for termination (38%) was appointment "no-shows" with some PCPs/clinics found to enforce a policy of dismissal following three no-shows. At the time of chart review, 201 patients (38%) had no documentation of a new PCP. Among patients who re-established care within the network, 134 (25%) had a primary care visit within 6 months of termination.
Detailed chart review found that, unlike previous survey-based studies, dismissal was often for missed appointments based on enforcement of no-show policies. Many sociodemographic factors were associated with termination. Variability among clinics highlights the need for further research to better understand circumstances surrounding terminations, with the principal goals of improving patient-provider relationships and providing equitable care.
医患关系是基层医疗的基石。这种关系的破裂和终止是研究不足但又很重要的不良结果。
更好地了解初级保健中提供者和诊所终止服务的性质和程度。
回顾性观察性病例对照研究。
2013 年 1 月至 2017 年 6 月期间，在马萨诸塞州东部的医院和社区诊所以及健康中心接受初级保健的成年患者，这些诊所参与了一个基于实践的研究网络。
初级保健医生（PCP）的正式终止、终止的原因、基于混合效应逻辑回归的终止的独立预测因素，以及终止后的新 PCP 的记录。
我们从 16 个诊所的 182 名 PCP 中确定了 158192 名接受初级保健的患者。我们发现了 536 例正式终止的病例。各诊所每 10000 名患者中有 4 至 119 例终止（组内相关系数[ICC]=0.21；95%置信区间[CI]：0.18-0.24）。患者年龄、种族/民族、教育程度、婚姻状况、就业状况和保险类型是终止的独立预测因素（例如，与全职就业的患者相比，因残疾而失业的患者更有可能被终止[调整后的比值比：9.26；95%CI：6.74-12.74]）。终止的最常见原因（38%）是预约“失约”，一些 PCP/诊所发现，在三次失约后，将执行解雇政策。在病历审查时，201 名患者（38%）没有新 PCP 的记录。在重新建立网络内医疗服务的患者中，有 134 名（25%）在终止后 6 个月内进行了初级保健就诊。
详细的病历审查发现，与之前的基于调查的研究不同，解雇通常是因为不遵守预约政策而导致的预约失约。许多社会人口因素与终止有关。诊所之间的差异突出表明需要进一步研究，以更好地了解终止的情况，主要目标是改善医患关系和提供公平的护理。
