Outpatient care fragmentation in Veterans Affairs patients at high-risk for hospitalization.
Outpatient care fragmentation in Veterans Affairs patients at high-risk for hospitalization.
复制标题
退伍军人事务部住院高风险患者的门诊护理分散。
DOI：
10.1111/1475-6773.13956
复制
发表时间：
2022
影响因子：
3.4
通讯作者：
Boothroyd,Derek
中科院分区：
文献类型：
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作者：
Zulman,DonnaM;Greene,Liberty;Slightam,Cindie;Singer,SaraJ;Maciejewski,MatthewL;Goldstein,MaryK;Vanneman,MeganE;Yoon,Jean;Trivedi,RanakB;Wagner,Todd;Asch,StevenM;Boothroyd,Derek
目的探讨住院高危患者门诊服务碎片化及其与未来住院的关系。数据来源退伍军人事务（VA）和医疗保险数据。研究设计我们进行了一项纵向研究，使用逻辑回归来检验2014财年门诊护理的分散程度（以独特提供者的数量、Breslau的常规护理提供者（UPC）、Bice‐Boxerman的护理连续性指数（COCI）和修改的修改连续性指数（MMCI）来衡量）与2015财年全因住院和与门诊护理敏感条件（ACSC）相关的住院之间的关系。我们还研究了患者年龄、性别、种族、民族、婚姻状况、农村状况、无家可归史、慢性病数量、医疗保险利用率和精神卫生保健利用率的差异。数据提取方法我们提取了130,704例≥65岁、住院风险≥90百分位数、基线年门诊次数≥4次的VA患者的数据。主要发现：2014财年门诊就诊的平均（SD）为13.2（8.6）。在慢性病较多的患者和接受精神卫生保健的患者中，碎片化护理（更多的提供者，较少的常规提供者的护理，更多的基于COCI的分散护理）更为常见。在调整后的模型中，大多数碎片化措施与全因住院无关，碎片化水平低的患者（基于UPC、COCI和MMCI的更集中的护理）发生ACSC相关住院的可能性更高（AOR， 95% CI分别为1.21（1.09‐1.35）、1.27（1.14‐1.42）和1.28(1.18‐1.40)）。与预期相反，门诊护理碎片化与住院风险前10%的VA患者全因住院率升高无关；事实上，支离破碎的护理与acsc的较低住院率有关。在像退伍军人管理局这样的综合环境中，多个提供者和分散的护理可能提供及时或专门的护理，以抵消分散的风险，特别是对于对门诊护理敏感的情况。
ObjectiveTo examine outpatient care fragmentation and its association with future hospitalization among patients at high risk for hospitalization.Data SourcesVeterans Affairs (VA) and Medicare data.Study DesignWe conducted a longitudinal study, using logistic regression to examine how outpatient care fragmentation in FY14 (as measured by number of unique providers, Breslau's Usual Provider of Care (UPC), Bice‐Boxerman's Continuity of Care Index (COCI), and Modified Modified Continuity Index (MMCI)) was associated with all‐cause hospitalizations and hospitalizations related to ambulatory care sensitive conditions (ACSC) in FY15. We also examined how fragmentation varied by patient's age, gender, race, ethnicity, marital status, rural status, history of homelessness, number of chronic conditions, Medicare utilization, and mental health care utilization.Data Extraction MethodsWe extracted data for 130,704 VA patients ≥65 years old with a hospitalization risk ≥90th percentile and ≥ four outpatient visits in the baseline year.Principal FindingsThe mean (SD) of FY14 outpatient visits was 13.2 (8.6). Fragmented care (more providers, less care with a usual provider, more dispersed care based on COCI) was more common among patients with more chronic conditions and those receiving mental health care. In adjusted models, most fragmentation measures were not associated with all‐cause hospitalization, and patients with low levels of fragmentation (more concentrated care based on UPC, COCI, and MMCI) had a higher likelihood of an ACSC‐related hospitalization (AOR, 95% CI = 1.21 (1.09‐1.35), 1.27 (1.14‐1.42), and 1.28 (1.18‐1.40), respectively).ConclusionsContrary to expectations, outpatient care fragmentation was not associated with elevated all‐cause hospitalization rates among VA patients in the top 10th percentile for risk of admission; in fact, fragmented care was linked to lower rates of hospitalization for ACSCs. In integrated settings such as the VA, multiple providers, and dispersed care might offer access to timely or specialized care that offsets risks of fragmentation, particularly for conditions that are sensitive to ambulatory care.