Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
J Am Geriatr Soc. 2024 Jul;72(7):2167-2173. doi: 10.1111/jgs.18872. Epub 2024 Mar 14.
Novel hospital diversion strategies are needed to support a growing number of patients with dementia living in the community. One promising model is community paramedicine (CP), which deploys paramedics to the home, who consult with a physician to coordinate treatment and assess disposition. While evidence suggests CP can manage many patients without escalation to the emergency department (ED), no studies have evaluated optimal CP utilization for patients with dementia. Therefore, we compare the use and outcomes of CP for homebound patients with and without dementia.
This retrospective cohort study examines 251 homebound patients receiving home-based primary care, who utilized a physician-led CP service between March 2017 and May 2022. Linked electronic health record data included patient demographics, clinical characteristics, and CP encounter details. Dementia status and CP outcomes, including rates of ED transport, over-transport (i.e., transported, but not hospitalized), and under-transport (i.e., not transported, but ED visit within 3 days), were determined via chart review. Using logistic regression, we modeled the association of dementia status with over- and under-transport, adjusting for age, sex, and chief complaint.
Fifty-three percent of CP patients had dementia. Their most common chief complaints were dyspnea (24.3%), altered mental status (17.9%), and generalized weakness (9.8%). We found no significant difference in ED transport rates by dementia status (25.4 vs. 22.8%, p = 0.54). Dementia diagnosis was associated with lower rates of over-transport (OR = 0.21, p = 0.03, CI [0.05, 0.85]) and comparable rates of under-transport (OR = 0.70, p = 0.47, CI [0.27, 1.83]) in adjusted models.
CP has effectively managed a diverse population of homebound patients with dementia cared for via home-based primary care. Future work should examine potential cost savings and use of CP in dementia care across geographic and healthcare settings.
需要新的医院转介策略来支持越来越多居住在社区中的痴呆症患者。一种有前途的模式是社区医疗（CP），它将护理人员派往家庭，与医生协商以协调治疗和评估处置。虽然有证据表明 CP 可以管理许多不需要升级到急诊部（ED）的患者，但没有研究评估 CP 对痴呆症患者的最佳利用。因此，我们比较了有和没有痴呆症的居家患者使用 CP 的情况和结果。
这项回顾性队列研究检查了 2017 年 3 月至 2022 年 5 月期间接受家庭初级保健的 251 名居家患者，他们使用了由医生领导的 CP 服务。链接的电子健康记录数据包括患者人口统计学、临床特征和 CP 就诊详细信息。通过病历审查确定痴呆症状态和 CP 结果，包括 ED 转运率、过度转运（即转运但未住院）和转运不足（即未转运但在 3 天内就诊 ED）。使用逻辑回归，我们通过调整年龄、性别和主要诉求，对痴呆症状态与过度和不足转运之间的关联进行建模。
53%的 CP 患者患有痴呆症。他们最常见的主要诉求是呼吸困难（24.3%）、精神状态改变（17.9%）和全身无力（9.8%）。我们没有发现痴呆症状态对 ED 转运率有显著影响（25.4%与 22.8%，p=0.54）。在调整后的模型中，痴呆症诊断与较低的过度转运率相关（OR=0.21，p=0.03，CI [0.05，0.85]）和相似的转运不足率（OR=0.70，p=0.47，CI [0.27，1.83]）。
CP 已经有效地管理了通过家庭初级保健照顾的患有痴呆症的居家患者的多样化人群。未来的工作应该研究在地理和医疗保健环境中，CP 在痴呆症护理中的潜在成本节约和使用。
