Early primary care provider follow-up and readmission after high-risk surgery.
Early primary care provider follow-up and readmission after high-risk surgery.
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DOI：
10.1001/jamasurg.2014.157
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发表时间：
2014-08
期刊：
影响因子：
16.9
通讯作者：
Goodney, Philip P.
中科院分区：
文献类型：
--
作者：
Brooke, Benjamin S.;Stone, David H.;Cronenwett, Jack L.;Nolan, Brian;DeMartino, Randall R.;MacKenzie, Todd A.;Goodman, David C.;Goodney, Philip P.
尽管没有明确的证据表明这可以改善预后，但通常建议对大手术后出院的患者进行除手术团队之外的初级保健提供者（PCP）的随访。为了测试 PCP 随访是否与开胸主动脉瘤 (TAA) 修复术和腹壁疝修补术 (VHR) 后 30 天再入院率降低相关，这两种手术分别具有高和低的再入院风险。在 2003 年至 2010 年间接受开放式 TAA 修复 (n = 12 679) 和 VHR (n = 52 807) 后出院回家的医疗保险受益人队列中，我们比较了出院 30 天内 PCP 诊治和未诊治的患者以及区域初级保健使用三分位数之间的 30 天再入院率。我们根据手术（指标）入院期间并发症的存在情况对分析进行分层。三十天再入院率。总体而言，2619 名接受开放 TAA 修复的患者（20.6%）和 4927 名接受 VHR 的患者（9.3%）在术后 30 天内重新入院。 4649 名接受开放 TAA 修复的患者（36.6%）和 4528 名接受 VHR 的患者（8.6%）在手术入院期间出现了并发症。 PCP 的早期随访显着降低了经历围手术期并发症的开放 TAA 患者的再入院风险，从 35.0%（无随访）降至 20.4%（有随访）（P < .001）。然而，PCP 随访对于住院病程不复杂的患者没有显着差异（有随访的患者为 19.4%，无随访的患者为 21.9%；P = .31）。相比之下，无论并发症如何，VHR 后早期 PCP 随访并不能降低再入院的风险。在调整后的区域分析中，与初级保健使用率低的地区相比，在初级保健使用率高的地区进行开放式 TAA 修复，30 天再入院的可能性降低 18%（比值比，0.82；95% CI，0.71–0.96；P = 0.02），而 VHR 后的患者之间没有发现显着差异。高风险手术（例如开放性 TAA 修复）后进行 PCP 随访，特别是对于有并发症的患者，可降低再入院的风险。接受低风险手术（例如 VHR）的患者不会从早期 PCP 随访中获得相同的益处。确定在护理过渡期间将受益于 PCP 整合的高风险手术患者可能会为限制再入院提供低成本解决方案。
Follow-up with a primary care provider (PCP) in addition to the surgical team is routinely recommended to patients discharged after major surgery despite no clear evidence that it improves outcomes. To test whether PCP follow-up is associated with lower 30-day readmission rates after open thoracic aortic aneurysm (TAA) repair and ventral hernia repair (VHR), surgical procedures known to have a high and low risk of readmission, respectively. In a cohort of Medicare beneficiaries discharged to home after open TAA repair (n = 12 679) and VHR (n = 52 807) between 2003 to 2010, we compared 30-day readmission rates between patients seen and not seen by a PCP within 30 days of discharge and across tertiles of regional primary care use. We stratified our analysis by the presence of complications during the surgical (index) admission. Thirty-day readmission rate. Overall, 2619 patients (20.6%) undergoing open TAA repair and 4927 patients (9.3%) undergoing VHR were readmitted within 30 days after surgery. Complications occurred in 4649 patients (36.6%) undergoing open TAA repair and 4528 patients (8.6%) undergoing VHR during their surgical admission. Early follow-up with a PCP significantly reduced the risk of readmission among open TAA patients who experienced perioperative complications, from 35.0% (without follow-up) to 20.4% (with follow-up) (P < .001). However, PCP follow-up made no significant difference in patients whose hospital course was uncomplicated (19.4% with follow-up vs 21.9% without follow-up; P = .31). In comparison, early follow-up with a PCP after VHR did not reduce the risk of readmission, regardless of complications. In adjusted regional analyses, undergoing open TAA repair in regions with high compared with low primary care use was associated with an 18% lower likelihood of 30-day readmission (odds ratio, 0.82; 95% CI, 0.71–0.96; P = .02), whereas no significant difference was found among patients after VHR. Follow-up with a PCP after high-risk surgery (eg, open TAA repair), especially among patients with complications, is associated with a lower risk of hospital readmission. Patients undergoing lower-risk surgery (eg, VHR) do not receive the same benefit from early PCP follow-up. Identifying high-risk surgical patients who will benefit from PCP integration during care transitions may offer a low-cost solution toward limiting readmissions.
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影响因子：
1.5
作者：
Greenwald JL;Jack BW
通讯作者：
Jack BW
影响因子：
1.9
作者：
POCOCK, SJ;GELLER, NL;TSIATIS, AA
通讯作者：
TSIATIS, AA
影响因子：
39.2
作者：
Jack BW;Chetty VK;Anthony D;Greenwald JL;Sanchez GM;Johnson AE;Forsythe SR;O'Donnell JK;Paasche-Orlow MK;Manasseh C;Martin S;Culpepper L
通讯作者：
Culpepper L
影响因子：
4.3
作者：
Brooke, Benjamin S.;Goodney, Philip P.;Stone, David H.
通讯作者：
Stone, David H.
影响因子：
3
作者：
Leduc, N;Tannenbaum, TN;Kogan, S
通讯作者：
Kogan, S