Canadian Partnership Against Cancer, Toronto, Canada.
Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, Maryland.
JAMA Netw Open. 2022 Jul 1;5(7):e2222056. doi: 10.1001/jamanetworkopen.2022.22056.
A better understanding of the association between early physician follow-up after discharge and adverse outcomes among hospitalized patients may inform interventions aimed at reducing readmission for common chronic conditions.
To assess whether hospitalized patients with early physician follow-up after discharge had lower rates of overall and condition-specific readmissions within 30 days and 90 days of discharge.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study was conducted among Ontario, Canada, adults with first admission for acute myocardial infarction (AMI), congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD) during 2005 to 2019. The exposure was follow-up visit with a primary care physician or relevant specialist within 7 days of discharge. Cox proportional hazards models were used to compare patients with vs without early follow-up, adjusting for sociodemographic factors and comorbidities, weighting by propensity score-based overlap weights. Data were analyzed from January through July 2021.
Primary outcomes were 30-day and 90-day readmissions, cardiac readmissions (readmission for AMI, CHF, or angina) for patients with cardiac conditions, and COPD-related readmissions for patients with COPD. Mortality at 30 days and 90 days was a secondary outcome. All percentages reported in Results are unweighted.
The study cohort comprised 450 746 patients, including 198 854 patients with AMI, 133 058 patients with CHF, and 118 834 patients with COPD; the median (IQR) age was 66 (56-77) years for AMI, 78 (68-85) years for CHF, and 73 (64-81) years for COPD, and there were 64 339 (32.35%) women, 62 575 (47.03%) women, and 59 179 (49.80%) women, respectively. There were 91 182 patients (45.85%), 56 491 patients (42.46%), and 40 159 patients (33.79%), respectively, who received an early follow-up visit. Overall, patients with early follow-up had higher rates of collaborative care (eg, CHF: 20 931 patients [37.85%] vs 11 101 of 76 567 patients [14.85%]) and visits to a specialist within 30 days (eg, CHF: 25 797 patients [45.67%] vs 20 548 patients [26.84%]). Those with early follow-up had lower 90-day readmission rates among patients with CHF (15 934 patients [28.21%] vs 23 121 patients [30.20%]; adjusted hazard ratio [aHR], 0.98; 95% CI, 0.96-0.99) and among those with COPD (8784 patients [21.87%] vs 18 097 of 78 675 patients [23.00%]; aHR, 0.95; 95% CI, 0.93-0.98). Among patients with COPD, those with early follow-up had lower 90-day COPD-related readmission rates (4015 patients [10.00%] vs 8449 patients [10.74%]; aHR, 0.93; 95% CI, 0.89-0.96), and among patients with CHF, those with early follow-up had lower 90-day mortality rates (4044 patients [7.16%] vs 6281 patients [8.20%]; aHR, 0.93; 95% CI, 0.90-0.97). There were no significant benefits at 30 days or for patients with AMI.
These findings suggest that early follow-up in conjunction with a comprehensive transitional care strategy for hospitalized patients with medically complex conditions coupled with ongoing effective chronic disease management may be associated with reduced 90-day readmissions.
更好地了解出院后早期医生随访与住院患者不良结局之间的关系，可能为减少常见慢性病患者再入院提供干预措施。
评估出院后早期接受医生随访的住院患者在出院后 30 天和 90 天内总体和特定疾病的再入院率是否较低。
设计、设置和参与者：这项队列研究在加拿大安大略省进行，研究对象为 2005 年至 2019 年期间首次因急性心肌梗死（AMI）、充血性心力衰竭（CHF）或慢性阻塞性肺疾病（COPD）入院的成年人。暴露因素是出院后 7 天内与初级保健医生或相关专家的随访就诊。采用 Cox 比例风险模型比较有和无早期随访的患者，调整社会人口因素和合并症，通过倾向评分匹配重叠权重进行加权。数据分析于 2021 年 1 月至 7 月进行。
主要结局是 30 天和 90 天的再入院率、有心脏疾病患者的心脏再入院率（再入院为 AMI、CHF 或心绞痛）和有 COPD 患者的 COPD 相关再入院率。30 天和 90 天的死亡率为次要结局。结果中报告的所有百分比均为未加权。
研究队列包括 450746 名患者，其中 198854 名患者患有 AMI，133058 名患者患有 CHF，118834 名患者患有 COPD；AMI 的中位（IQR）年龄为 66（56-77）岁，CHF 为 78（68-85）岁，COPD 为 73（64-81）岁，分别有 64339 名（32.35%）、62575 名（47.03%）和 59179 名（49.80%）女性。分别有 91182 名（45.85%）、56491 名（42.46%）和 40159 名（33.79%）患者接受了早期随访。总的来说，接受早期随访的患者协同护理（如 CHF：20931 名[37.85%]与 76567 名中的 11101 名[14.85%]）和 30 天内专科就诊（如 CHF：25797 名[45.67%]与 20548 名[26.84%]）的比例较高。在 CHF 患者中，早期随访者 90 天再入院率较低（15934 名[28.21%]与 23121 名[30.20%]；调整后的危险比[aHR]，0.98；95%CI，0.96-0.99）和 COPD 患者中（8784 名[21.87%]与 78675 名中的 18097 名[23.00%]；aHR，0.95；95%CI，0.93-0.98）。在 COPD 患者中，早期随访者 90 天 COPD 相关再入院率较低（4015 名[10.00%]与 78675 名中的 8449 名[10.74%]；aHR，0.93；95%CI，0.89-0.96），而在 CHF 患者中，早期随访者 90 天死亡率较低（4044 名[7.16%]与 6281 名[8.20%]；aHR，0.93；95%CI，0.90-0.97）。在 30 天或 AMI 患者中没有显著获益。
这些发现表明，对于患有复杂医疗条件的住院患者，结合全面的过渡性护理策略和持续有效的慢性病管理，早期随访可能与降低 90 天再入院率相关。
