Rask K J, Williams M V, McNagny S E, Parker R M, Baker D W
Department of Medicine, Emory University School of Medicine, Emory University Center for Clinical Evaluation Sciences, Atlanta, GA 30303, USA.
J Gen Intern Med. 1998 Sep;13(9):614-20. doi: 10.1046/j.1525-1497.1998.00184.x.
To describe primary care clinic use and emergency department (ED) use for a cohort of public hospital patients seen in the ED, identify predictors of frequent ED use, and ascertain the clinical diagnoses of those with high rates of ED use.
Cohort observational study.
A public hospital in Atlanta, Georgia.
Random sample of 351 adults initially surveyed in the ED in May 1992 and followed for 2 years.
Of the 351 patients from the initial survey, 319 (91%) had at least one ambulatory visit in the public hospital system during the following 2 years and one third of the cohort was hospitalized. The median number of subsequent ED visits was 2 (mean 6.4), while the median number of visits to a primary care appointment clinic was O (mean 1.1) with only 90 (26%) of the patients having any primary care clinic visits. The 58 patients (16.6%) who had more than 10 subsequent ED visits accounted for 65.6% of all subsequent ED visits. Overall, patients received 55% of their subsequent ambulatory care in the ED, with only 7.5% in a primary care clinic. In multivariate regression, only access to a telephone (odds ratio [OR] 0.48; 95% confidence interval [CI] 0.39, 0.60), hospital admission (OR 5.90; 95% CI 4.01, 8.76), and primary care visits (OR 1.68; 95% CI 1.34, 2.12) were associated with higher ED visit rates. Regular source of care, insurance coverage, and health status were not associated with ED use. From clinical record review, 74.1% of those with high rates of use had multiple chronic medical conditions, or a chronic medical condition complicated by a psychiatric diagnosis, or substance abuse.
All subgroups of patients in this study relied heavily on the ED for ambulatory care, and high ED use was positively correlated with appointment clinic visits and inpatient hospitalization rates, suggesting that high resource utilization was related to a higher burden of illness among those patients. The prevalence of chronic medical conditions and substance abuse among these most frequent emergency department users points to a need for comprehensive primary care. Multidisciplinary case management strategies to identify frequent ED users and facilitate their use of alternative care sites will be particularly important as managed care strategies are applied to indigent populations who have traditionally received care in public hospital EDs.
描述急诊科就诊的一批公立医院患者对初级保健诊所的利用情况以及对急诊科的利用情况，确定频繁使用急诊科的预测因素，并查明急诊科使用率高的患者的临床诊断。
队列观察性研究。
佐治亚州亚特兰大的一家公立医院。
1992年5月在急诊科接受初次调查的351名成年人的随机样本，并随访2年。
在初次调查的351名患者中，319名（91%）在随后2年内在公立医院系统至少有一次门诊就诊，三分之一的队列患者住院治疗。后续急诊科就诊的中位数为2次（平均6.4次），而初级保健预约诊所就诊的中位数为0次（平均1.1次），只有90名（26%）患者有任何初级保健诊所就诊经历。58名（16.6%）后续急诊科就诊超过10次的患者占所有后续急诊科就诊次数的65.6%。总体而言，患者后续门诊护理的55%是在急诊科接受的，只有7.5%是在初级保健诊所接受的。在多变量回归分析中，只有能使用电话（比值比[OR]0.48；95%置信区间[CI]0.39，0.60）、住院治疗（OR 5.90；95%CI 4.01，8.76）和初级保健就诊（OR 1.68；95%CI 1.34，2.12）与较高的急诊科就诊率相关。常规护理来源、保险覆盖范围和健康状况与急诊科利用情况无关。通过临床记录审查发现，使用率高的患者中74.1%患有多种慢性疾病，或患有合并精神疾病诊断的慢性疾病，或存在药物滥用问题。
本研究中所有患者亚组在门诊护理方面都严重依赖急诊科，急诊科高使用率与预约诊所就诊率和住院率呈正相关，这表明高资源利用率与这些患者中较高的疾病负担有关。这些最频繁使用急诊科的患者中慢性疾病和药物滥用的患病率表明需要全面的初级保健。随着管理式医疗策略应用于传统上在公立医院急诊科接受治疗的贫困人群，识别频繁使用急诊科的患者并促进他们使用替代护理场所的多学科病例管理策略将尤为重要。
