Recchia K C, Petros T M, Spooner S A, Cranshaw J L
Department of Pediatrics, Washington University School of Medicine, St Louis, MO 63110, USA.
Pediatrics. 1995 Jul;96(1 Pt 1):90-8.
To determine the feasibility of implementing the Community Outpatient Practice Experience (COPE), a community-based continuity program, in a large, tertiary-care-oriented pediatric residency; to assess the impact of the continuity program on pediatric residents' experience; and to compare the experience in a variety of community practice settings.
Continuity clinic settings included a hospital-based residents' group practice (RGP) clinic (1989 through 1991) and a community-based program in which each resident was paired with a practicing pediatrician in the community (1991 through 1993). Community practice types included publicly funded clinics (n = 9), private practices (n = 38), and managed-care practices (n = 14). In all settings, residents spent half a day per week in continuity activity.
Measures of resident's experience (patient encounters, patient age distribution, and diagnostic mix) were compared in both settings and among community practice types. RGP data were derived from a patient scheduling database, and COPE data were obtained from patient encounter records submitted by each resident.
Residents in RGP (108.5 resident years) had 5294-encounters with 1568 patients. In COPE (102.5 resident years), 21,978 encounters with 19,235 patients occurred. COPE residents saw significantly more patients per session (6.2 vs 1.7) than residents in RGP. The mean patient age in COPE was significantly higher than RGP (5.3 vs 2.6 years). A greater proportion of encounters in RGP were for health supervision (61% vs 30%), but a greater number of health supervision encounters per resident occurred in COPE. There was a higher proportion of patients with chronic disease in RGP (38% vs 7%), but a greater number of patients with chronic disease was seen per resident in COPE. Analysis of COPE data by practice type showed fewer patient encounters per session and a younger patient age in publicly funded sites than in private- or managed-care practices. The proportion of health supervision encounters was greatest in publicly funded sites, but the greatest number of health supervision encounters per resident occurred in managed-care practices.
We successfully integrated a large-scale community-based continuity experience into a large, tertiary-care-oriented pediatric residency program. We present COPE as an alternative to the hospital-based continuity clinic and suggest it as a model for improving residents' primary-care experience.
确定在一个大型的、以三级医疗为导向的儿科住院医师培训项目中实施基于社区的连续性项目——社区门诊实践经验（COPE）的可行性；评估该连续性项目对儿科住院医师经验的影响；并比较在各种社区实践环境中的经验。
连续性诊所环境包括一个基于医院的住院医师团体诊所（RGP）（1989年至1991年）和一个基于社区的项目，其中每个住院医师与社区中的一名执业儿科医生配对（1991年至1993年）。社区实践类型包括公共资助诊所（n = 9）、私人诊所（n = 38）和管理式医疗诊所（n = 14）。在所有环境中，住院医师每周花半天时间进行连续性活动。
比较两种环境以及不同社区实践类型中住院医师经验的指标（患者诊疗次数、患者年龄分布和诊断组合）。RGP数据来自患者排班数据库，COPE数据来自每位住院医师提交的患者诊疗记录。
RGP的住院医师（108.5住院医师年）对1568名患者进行了5294次诊疗。在COPE（102.5住院医师年）中，对19235名患者进行了21978次诊疗。COPE的住院医师每次诊疗的患者数量显著多于RGP的住院医师（6.2例对1.7例）。COPE中患者的平均年龄显著高于RGP（5.3岁对2.6岁）。RGP中更大比例的诊疗是为了健康监督（61%对30%），但每位住院医师在COPE中进行的健康监督诊疗次数更多。RGP中患有慢性病的患者比例更高（38%对7%），但每位住院医师在COPE中见到的慢性病患者数量更多。按实践类型对COPE数据进行分析显示，公共资助场所每次诊疗的患者次数较少，患者年龄较私人或管理式医疗场所更小。公共资助场所中健康监督诊疗的比例最大，但每位住院医师在管理式医疗场所进行的健康监督诊疗次数最多。
我们成功地将大规模的基于社区的连续性经验整合到一个大型的、以三级医疗为导向的儿科住院医师培训项目中。我们将COPE作为基于医院的连续性诊所的替代方案，并建议将其作为改善住院医师初级医疗经验的模式。
