Bannett Yair, Gardner Rebecca M, Huffman Lynne C, Feldman Heidi M, Sanders Lee M
Division of Developmental-Behavioral Pediatrics (Y Bannett, LC Huffman and HM Feldman), Stanford University School of Medicine, Stanford, Calif.
Stanford Quantitative Sciences Unit (RM Gardner), Stanford, Calif.
Acad Pediatr. 2023 Mar;23(2):314-321. doi: 10.1016/j.acap.2022.07.012. Epub 2022 Jul 17.
Retrospective cohort study of electronic health records from office visits of children <9 years, seen ≥4 times between 2015 and 2019 in 10 practices of a community-based primary health care network in California. Three cohorts were constructed: 1) Asthma: ≥2 visits with asthma visit diagnoses; 2) ASD: same method; 3) Controls: no chronic conditions. CoC, using Usual Provider of Care measure (range > 0-1), was calculated for 1) all visits (overall) and 2) well-care visits. Fractional regression models examined CoC adjusting for patient age, medical insurance, practice affiliation, and number of visits.
Of 30,678 children, 1875 (6.1%) were classified with Asthma, 294 (1.0%) with ASD, and 15,465 (50.4%) as Controls. Overall CoC was lower for Asthma (Mean = 0.58, SD 0.21) and ASD (M = 0.57, SD = 0.20) than Controls (M = 0.66, SD = 0.21); differences in well-care CoC were minimal. In regression models, lower overall CoC was found for Asthma (aOR = 0.90, 95% CI, 0.85-0.94). Lower overall and well-care CoC were associated with public insurance (aOR = 0.77, CI, 0.74-0.81; aOR = 0.64, CI, 0.59-0.69).
After accounting for patient and clinical-care factors, children with asthma, but not with ASD, in this primary-care network had significantly lower CoC compared to children without chronic conditions. Public insurance was the most prominent patient factor associated with low CoC, emphasizing the need to address disparities in CoC.
1）评估哮喘和自闭症谱系障碍（ASD）儿童在初级保健机构中的连续护理（CoC）情况，并与无慢性病儿童进行比较；2）确定与连续护理相关的患者和临床护理因素。
对加利福尼亚州一个社区初级卫生保健网络的10家医疗机构中2015年至2019年间就诊≥4次的9岁以下儿童的电子健康记录进行回顾性队列研究。构建了三个队列：1）哮喘队列：有≥2次哮喘就诊诊断；2）自闭症谱系障碍队列：方法相同；3）对照组：无慢性病。使用常规护理提供者测量法（范围>0 - 1）计算1）所有就诊（总体）和2）健康护理就诊的连续护理情况。分数回归模型在调整患者年龄、医疗保险、医疗机构隶属关系和就诊次数后检验连续护理情况。
在30678名儿童中，1875名（6.1%）被归类为哮喘患者，294名（1.0%）为自闭症谱系障碍患者，15465名（50.4%）为对照组。哮喘组（均值 = 0.58，标准差0.21）和自闭症谱系障碍组（均值 = 0.57，标准差 = 0.20）的总体连续护理情况低于对照组（均值 = 0.66，标准差 = 0.21）；健康护理连续护理情况的差异最小。在回归模型中，哮喘组的总体连续护理情况较低（调整后比值比 = 0.90，95%置信区间，0.85 - 0.94）。总体和健康护理连续护理情况较低与公共保险相关（调整后比值比 = 0.77，置信区间，0.74 - 0.81；调整后比值比 = 0.64，置信区间，0.59 - 0.69）。
在考虑患者和临床护理因素后，该初级保健网络中患有哮喘但非自闭症谱系障碍的儿童与无慢性病儿童相比，连续护理情况显著较低。公共保险是与低连续护理情况相关的最突出患者因素，强调了消除连续护理差异的必要性。
