Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans
Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans
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DOI：
10.1001/jamanetworkopen.2020.8120
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发表时间：
2020-06-29
影响因子：
13.8
通讯作者：
Rubenstein, Lisa, V
中科院分区：
文献类型：
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作者：
Chang, Evelyn T.;Zulman, Donna M.;Rubenstein, Lisa, V
这项横断面研究评估了退伍军人健康管理局中高住院风险患者使用普通和专门初级保健、医疗专科和精神卫生服务的情况。重要的综合医疗保健系统越来越重视改善高住院风险患者的预后。检查患者在哪里获得护理的模式可以使卫生保健系统洞察如何开发高危患者护理的方法；然而，这种信息很少被描述。目的评估退伍军人健康管理局(VHA)高危住院患者对普通和专科初级保健、医学专科和精神卫生服务的利用情况。设计、设置和参与者这项全国性、以人群为基础的回溯性横断面研究包括了截至2015年9月30日登记参加任何类型的VHA初级保健服务的所有退伍军人。数据分析时间为2016年4月1日至2019年1月1日。暴露住院和分配到普通初级保健与专门初级保健的风险。主要结果和指标高危退伍军人被定义为根据有效的风险预测模型，近期住院风险最高5%的人；其他所有人被认为是低风险。卫生保健服务的使用是通过在普通初级保健、专科初级保健、医学专科、精神卫生、急诊科和附加强化管理服务(例如远程保健和姑息护理)中遇到的次数来衡量的。结果本研究评估了192名退伍军人(平均年龄62.6[16.0]岁；93%为男性)。男性退伍军人(93%；优势比[OR]，1.11；95%CI，1.10-1.13)，未婚退伍军人(63%；OR，2.30；95%CI，2.32-2.35)，45岁以上(94%；45-65岁：OR，3.49[95%CI，3.44-3.54]；66-75岁：OR，3.04[95%CI，3.00-3.09]；和GT；75岁：OR 2.42[95%CI，2.38-2.46]；黑人退伍军人(23%；OR，1.63；95%CI，1.61-1.64)；合并内科疾病者(哮喘或慢性阻塞性肺疾病：33%；OR，4.03[95%CI，4.00-4.06]；精神分裂症：4%；OR：5.14[95%CI，5.05-5.22]；抑郁症：42%；OR3.10[95%CI，3.08-3.13]和酗酒：20%；OR，4.54[95%CI，4.50-4.59]是高危人群(n=351和x202f；012)。大多数(308和x202f；433[88%])高危退伍军人被分配到普通初级保健；其余12%(363 561人中的42和x202f；579)被分配到专门的初级保健(例如，妇女健康和无家可归)。被分配到普通初级保健的高危患者比被分配到专门初级保健的高危患者有更频繁的初级保健就诊(平均每年6.9[SD]，6.9[6.5]次；P<；.001)。他们也有更多的医疗专科护理(平均每年4.4[5.9]比3.7[5.4]；P<；.001)和较少的精神健康(平均[SD]，9.0[21.6]比11.3[23.9]每年；P<；.001)。强化辅助门诊服务的使用率总体较低。结论和相关性研究结果表明，在综合卫生保健系统中，支持高危患者护理的方法应该嵌入普通初级保健和精神卫生保健中，如果它们要改善高危患者人群的预后。退伍军人健康管理局内的问题是，普通初级保健、专门初级保健、心理健康和医学专科服务在照顾住院高危退伍军人方面扮演什么角色？在这项横断面研究中发现，高风险住院退伍军人的心理健康遭遇显著多于初级保健遭遇，初级保健遭遇显著多于医疗专科遭遇。大多数高危退伍军人(88%)在普通初级保健中得到照顾，而不是在专门的初级保健中。这意味着，研究结果表明，卫生保健系统领导人应该认识到普通初级保健和心理健康对高危患者的关键作用。
This cross-sectional study assesses the use of general and specialized primary care, medical specialty, and mental health services among patients aat high risk of hospitalization in the Veterans Health Administration.Importance Integrated health care systems increasingly focus on improving outcomes among patients at high risk for hospitalization. Examining patterns of where patients obtain care could give health care systems insight into how to develop approaches for high-risk patient care; however, such information is rarely described. Objective To assess use of general and specialized primary care, medical specialty, and mental health services among patients at high risk of hospitalization in the Veterans Health Administration (VHA). Design, Setting, and Participants This national, population-based, retrospective cross-sectional study included all veterans enrolled in any type of VHA primary care service as of September 30, 2015. Data analysis was performed from April 1, 2016, to January 1, 2019. Exposures Risk of hospitalization and assignment to general vs specialized primary care. Main Outcome and Measures High-risk veterans were defined as those who had the 5% highest risk of near-term hospitalization based on a validated risk prediction model; all others were considered low risk. Health care service use was measured by the number of encounters in general primary care, specialized primary care, medical specialty, mental health, emergency department, and add-on intensive management services (eg, telehealth and palliative care). Results The study assessed 4 & x202f;309 & x202f;192 veterans (mean [SD] age, 62.6 [16.0] years; 93% male). Male veterans (93%; odds ratio [OR], 1.11; 95% CI, 1.10-1.13), unmarried veterans (63%; OR, 2.30; 95% CI, 2.32-2.35), those older than 45 years (94%; 45-65 years of age: OR, 3.49 [95% CI, 3.44-3.54]; 66-75 years of age: OR, 3.04 [95% CI, 3.00-3.09]; and >75 years of age: OR, 2.42 [95% CI, 2.38-2.46]), black veterans (23%; OR, 1.63; 95% CI, 1.61-1.64), and those with medical comorbidities (asthma or chronic obstructive pulmonary disease: 33%; OR, 4.03 [95% CI, 4.00-4.06]; schizophrenia: 4%; OR, 5.14 [95% CI, 5.05-5.22]; depression: 42%; OR, 3.10 [95% CI, 3.08-3.13]; and alcohol abuse: 20%; OR, 4.54 [95% CI, 4.50-4.59]) were more likely to be high risk (n = 351 & x202f;012). Most (308 & x202f;433 [88%]) high-risk veterans were assigned to general primary care; the remaining 12% (42 & x202f;579 of 363 561) were assigned to specialized primary care (eg, women's health and homelessness). High-risk patients assigned to general primary care had more frequent primary care visits (mean [SD], 6.9 [6.5] per year) than those assigned to specialized primary care (mean [SD], 6.3 [7.3] per year; P < .001). They also had more medical specialty care visits (mean [SD], 4.4 [5.9] vs 3.7 [5.4] per year; P < .001) and fewer mental health visits (mean [SD], 9.0 [21.6] vs 11.3 [23.9] per year; P < .001). Use of intensive supplementary outpatient services was low overall. Conclusions and Relevance The findings suggest that, in integrated health care systems, approaches to support high-risk patient care should be embedded within general primary care and mental health care if they are to improve outcomes for high-risk patient populations.Question Within the Veterans Health Administration, what is the role of general primary care, specialized primary care, mental health, and medical specialty services in caring for veterans at high risk for hospitalization? Findings In this cross-sectional study, veterans at high risk for hospitalization had significantly more mental health encounters than primary care encounters and significantly more primary care encounters than medical specialty encounters. Most high-risk veterans (88%) were cared for in general primary care rather than in specialized primary care. Meaning The findings suggest that health care system leaders should recognize the critical roles of general primary care and mental health for high-risk patients.