Department of Medicine, Weill Cornell Medicine, New York, New York, USA
University of St Andrews, St Andrews, UK.
BMJ Open. 2024 Nov 2;14(11):e081533. doi: 10.1136/bmjopen-2023-081533.
Receiving care at patient-centred medical homes (PCMH) is associated with reduced emergency department (ED) visits among children. Adverse social determinants of health (SDoH), such as lower socioeconomic status and household poverty, are associated with increased ED visits in children. The objective of this study is to use machine learning techniques to understand the relative importance of each PCMH component among different populations with adverse SDoH on the outcome of ED visits.
METHODS DESIGN, SETTING AND PARTICIPANTS: This study used the 2018-2019 pooled data from the National Survey of Children's Health (NSCH), an annual survey of parents and caregivers of US children from birth to 17 years. PCMH components were operationalised by classifying parent/caregiver responses into five domains: care coordination (CC), having a personal doctor or nurse, having a usual source of care, family-centred care and ease of getting referrals. SDoH included five categories: (1) social and community context, (2) economic stability, (3) education access and quality, (4) healthcare access and quality and (5) neighbourhood and built environment.
We used a split-improvement variable importance measure based on random forests to determine the importance of PCMH domains on ED visits overall and stratified by SDoH.
Overall, between 3% and 28% experienced one or more gaps in PCMH domains. Models show that problems with referrals (rank, 2; Gini, 83.5) and gaps in CC (rank, 3; Gini, 81.0) were the two most important domains of PCMH associated with ED visits in children. This result was consistent among black and Hispanic children and among children with lower socioeconomic status.
Our study findings underscore the importance of poor CC and referrals on ED visits for all children and those from disadvantaged populations. Initiatives for expanding the reach of PCMH should consider prioritising these two domains, especially in areas with significant minority populations.
在以患者为中心的医疗之家（PCMH）接受治疗与儿童急诊就诊次数减少有关。不利的健康社会决定因素（SDoH），如较低的社会经济地位和家庭贫困，与儿童急诊就诊次数增加有关。本研究的目的是使用机器学习技术了解在具有不利 SDoH 的不同人群中，每个 PCMH 成分对急诊就诊结果的相对重要性。
方法设计、地点和参与者：本研究使用了 2018-2019 年全国儿童健康调查（NSCH）的汇总数据，这是一项对美国 0 至 17 岁儿童的父母和照顾者进行的年度调查。PCMH 成分通过将父母/照顾者的回答分类为五个领域来操作：协调护理（CC）、有私人医生或护士、有常规医疗服务、以家庭为中心的护理和获得转诊的便利性。SDoH 包括五个类别：（1）社会和社区环境，（2）经济稳定，（3）教育机会和质量，（4）医疗保健机会和质量，（5）邻里和建筑环境。
我们使用基于随机森林的分割改进变量重要性测量来确定 PCMH 领域对总体急诊就诊以及按 SDoH 分层的重要性。
总体而言，有 3%至 28%的儿童经历了一个或多个 PCMH 领域的差距。模型显示，转诊问题（排名 2；基尼系数 83.5）和 CC 差距（排名 3；基尼系数 81.0）是与儿童急诊就诊最相关的两个最重要的 PCMH 领域。这一结果在黑人和西班牙裔儿童以及社会经济地位较低的儿童中是一致的。
我们的研究结果强调了 CC 差和转诊对所有儿童和弱势人群急诊就诊的重要性。扩大 PCMH 覆盖面的倡议应考虑优先考虑这两个领域，特别是在少数民族人口众多的地区。
