Patient-Reported Access in the Patient-Centered Medical Home and Avoidable Hospitalizations: an Observational Analysis of the Veterans Health Administration
Patient-Reported Access in the Patient-Centered Medical Home and Avoidable Hospitalizations: an Observational Analysis of the Veterans Health Administration
复制标题
DOI：
10.1007/s11606-019-05060-0
复制
发表时间：
2019-08-01
影响因子：
5.7
通讯作者：
Wong, Edwin S.
中科院分区：
文献类型：
--
作者：
Augustine, Matthew R.;Nelson, Karin M.;Wong, Edwin S.
背景：以患者为中心的医疗之家(PCMH)强调及时获得初级保健，通常使用非传统的提供方式，如下班后亲自护理或在正常工作时间或下班后通过电话护理。关于改善患者报告的这些服务类型是否可以减少住院，目前数据有限。目的：检查退伍军人健康管理局(VHA)内通过五种服务类型获得初级保健的患者与因门诊敏感疾病(ACSC)住院的患者之间的关联。设计：回溯性队列研究，使用多变量Logistic回归调整患者的人口统计学、合并症、患者居住地的特征和临床水平的随机影响。PARTICIPANTS：共有69,710名VHA初级保健患者回答了2012年患者医疗体验调查(SHEP)，PCMH模块。MAIN测量：调查问题收集了患者从VHA获得五种服务类型的能力：常规护理、即时护理、下班后护理、正常办公时间电话护理和正常工作时间以外电话护理。结果包括VHA管理数据和医疗保险服务费用索赔中确定的2013年总体、急性和慢性ACSCs住院的两种衡量标准。KEY结果：报告始终能够获得下班后护理的患者与从未获得过的患者相比，因慢性ACSCs住院的可能性较低(OR0.62，95%CI0.44-0.89，p=0.009)。报告通常在正常时间通过电话接受治疗的患者更有可能因慢性ACSC而住院(OR1.49，95%CI1.03-2.17，p=0.034)。常规护理、即时护理和下班后电话护理的经验表明，与ACSC的住院没有显著关联。结论：提高患者获得下班后护理的能力与慢性ACSCs的住院次数减少有关，而在正常时间通过电话获得护理与住院次数增加相关。卫生系统应考虑与实施每项PCMH服务的成本相比的好处，包括减少慢性ACSCs的住院率。
BACKGROUND: The Patient-Centered Medical Home (PCMH) has emphasized timely access to primary care, often by using non-traditional modes of delivery, such as care in person after-hours or by phone during or after normal hours. Limited data exists on whether improving patient-reported access with these service types reduces hospitalization.OBJECTIVe: To examine the association of patient-reported access to primary care within the Veteran Health Administration (VHA) via five service types and hospitalizations for ambulatory care sensitive conditions (ACSCs).DESIGN: Retrospective cohort study, using multivariable logistic regression adjusting for patient demographics, comorbidity, characteristics of patients' area of residence, and clinic-level random effects.PARTICIPANTS: A total of 69,710 VHA primary care patients who responded to the 2012 Survey of Healthcare Experiences of Patients (SHEP), PCMH module.MAIN MEASURES: Survey questions captured patients' ability to obtain care from VHA for five service types: routine care, immediate care, after-hours care, care by phone during regular office hours, and care by phone after normal hours. Outcomes included binary measures of hospitalization for overall, acute, and chronic ACSCs in 2013, identified in VHA administrative data and Medicare fee-for-service claims.KEY RESULTS: Patients who reported always able to obtain after-hours care compared to never were less likely to be hospitalized for chronic ACSCs (OR 0.62, 95% CI 0.44-0.89, p = 0.009). Patients reporting usually getting care by phone during regular hours were more likely have a hospitalization for chronic ACSC (OR 1.49, 95% CI 1.03-2.17, p = 0.034). Experiences with routine care, immediate care, and care by phone after-hours demonstrated no significant association with hospitalization for ACSCs.CONCLUSIONS: Improving patients' ability to obtain after-hours care was associated with fewer hospitalizations for chronic ACSCs, while access to care by phone during regular hours was associated with more hospitalizations. Health systems should consider the benefits, including reduced hospitalizations for chronic ACSCs, against the costs of implementing each of these PCMH services.