Fragmentation of care for frequently hospitalized urban residents
Fragmentation of care for frequently hospitalized urban residents
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DOI：
10.1097/01.mlr.0000215811.68308.ae
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发表时间：
2006-06-01
期刊：
影响因子：
3
通讯作者：
Bach, PB
中科院分区：
文献类型：
--
作者：
Schrag, D;Xu, F;Bach, PB
背景：各个护理地点的分散可能会阻碍高效的医疗服务。目的：本研究的目的是评估纽约市 (NYC) 慢性病居民医院护理的分散性及其与纽约州 (NYS) 医疗补助计划注册的关系。 研究设计：我们利用纽约州卫生部的全州规划和研究合作系统出院数据库进行了一项横断面研究。我们确定了 53,031 名纽约市居民，他们在 2000 年至 2002 年间曾 3 次或多次住进急症护理医院，其主要诊断结果都是相同的特定慢性疾病（糖尿病、镰状细胞性贫血、精神病、药物滥用、癌症、胃肠道疾病、慢性阻塞性肺病/哮喘、冠状动脉疾病或充血性心力衰竭）。我们还评估了一个由 225,421 名患者组成的更大队列，这些患者因某种特定慢性病入院次数≥3 次，被编码为主要或次要诊断。使用广义 Logit 模型来检查碎片化与每个患者的主要保险之间的关系，根据诊断和人口特征进行调整。测量：根据患者就诊的不同医院数量相对于患者在 3 年时间间隔内住院的总数，碎片化被描述为高、中或低。结果：在经常住院的患有特定慢性病的纽约市居民中，17.1% 经历过高度碎片化的护理。购买商业保险的患者的这一比例为 9.9%，购买 Medicaid 的患者为 24.4%，购买 Medicare 的患者为 9.7%。与商业保险患者相比，描述医疗补助参与者高度分散的未经调整优势比为 3.82（95% 置信区间 [CI]，3.50-4.18），尽管有所减弱，但在调整人口特征后仍然显着（优势比，1.33；95% CI，1.20-1.47）。碎片化的最强预测因子是精神病（OR，2.81；95% CI，2.43-3.25）或药物滥用（OR，7.58；95% CI，6.55-8.77）的诊断。结论：在纽约市，医疗补助登记与医院护理的更大碎片化有关，但这在很大程度上归因于医疗补助参与者中大多数被诊断为精神病和药物滥用。提高医疗保健服务效率的策略应重点关注经常入住综合医院的精神疾病患者。
Background: Fragmentation across sites of care may impede efficient healthcare delivery. Objectives: The objectives of this study were to evaluate fragmentation of hospital care for chronically ill New York City (NYC) residents and its association with enrollment in the New York State (NYS) Medicaid program.Research Design: We conducted a cross-sectional study using the NYS Department of Health's Statewide Planning and Research Cooperative System discharge database. We identified 53,031 NYC residents admitted 3 or more times to acute care hospitals between 2000 and 2002 with the same principal diagnosis of a specific chronic illness (diabetes, sickle cell anemia, psychosis, substance abuse, cancer, gastrointestinal disease, chronic obstructive pulmonary disease/asthma, coronary artery disease, or congestive heart failure). We also evaluated a larger cohort of 225,421 patients with >= 3 admissions for a specific chronic illness coded as either the principal or a secondary diagnosis. A generalized logit model was used to examine the relationship between fragmentation and each patient's primary insurance adjusted for diagnosis and demographic characteristics.Measures: Fragmentation was characterized as high, moderate, or low based on the number of distinct hospitals a patient visited relative to the patient's total number of hospitalizations over the 3-year interval.Results: Among frequently hospitalized NYC residents with select chronic conditions, 17.1% experienced highly fragmented care. This rate was 9.9% for patients with commercial insurance, 24.4% for those with Medicaid, and 9.7% for those with Medicare. The unadjusted odds ratio describing high fragmentation of Medicaid enrollees compared with commercially insured patients was 3.82 (95% confidence interval [CI], 3.50-4.18) and, although attenuated, remained significant after adjustment for demographic characteristics (odds ratio, 1.33; 95% CI, 1.20-1.47). The strongest predictor of fragmentation was a diagnosis of psychosis (OR, 2.81; 95% CI, 2.43-3.25) or substance abuse (OR, 7.58; 95% CI, 6.55-8.77).Conclusions: In NYC, Medicaid enrollment is associated with greater fragmentation of hospital care, but this is largely attributable to the preponderance of Medicaid enrollees with diagnoses of psychosis and substance abuse. Strategies to improve the efficiency of healthcare delivery should focus on patients with mental illness who are frequently admitted to general hospitals.