دانلود رایگان ترجمه مقاله بهبود پیگیری مراقبت های تخصصی پس از ویزیت بخش اورژانس (نشریه الزویر ۲۰۱۳)

بهبود پیگیری مراقبت های تخصصی پس از ویزیت بخش اورژانس با استفاده از نظام ارجاع منحصر به فرد

Improving specialty care follow-up after an ED visit using a unique referral system

Abstract

Objective Many patients discharged from the emergency department (ED) require urgent follow-up with specialty providers. We hypothesized that a unique specialty referral mechanism that minimized barriers would increase follow-up compliance over reported and historical benchmarks.

Methods Retrospective review of all patients requiring urgent (within 1 month) specialty referrals in 2010 from a safety net hospital ED to dermatology, otolaryngology, neurology, neurosurgery, ophthalmology, urology, plastic surgery, general surgery, or vascular surgery clinics. After specialist input, all patients received a specific follow-up appointment before ED discharge via a specific scheduling service. Necessity for payment at the follow-up visit was waived.

Results Of the 1174 receiving referrals, 85.6% of patients scheduled an appointment and 80.1% kept that appointment. After logistic regression analysis, the factors that remained significantly associated (P < .05) with appointment-keeping compliance were the specialty clinic type (dermatology, 61.5%, to ophthalmology, 98.0%), insurance status (other payer, 87.5%; commercial, 82.8%; Medicaid, 77.9%; Medicare, 85.7%; charity care program, 88.1%; self-pay, 73.0%), age (< 18 years, 80.1%; 18-34 years, 75.0%; 35-49 years, 79.2%; 50-64 years, 85.9 %; > 64 years, 93.9%), and mean length of time between ED visit and clinic appointment (kept, 10.5 days; not kept, 14.3 days). The specialty clinic (neurology, 72.8%, to vascular surgery, 100%; P < .001) was significantly associated with the likelihood of patients to complete the appointment-making process. Race/Ethnicity was not associated with either scheduling or keeping an appointment.

Conclusion A referral process that minimizes barriers can achieve an 80% follow-up compliance rate. Age, insurance, specialty type, and time to appointment are associated with noncompliance.

۱ Introduction

Specialty care referral is often unavailable to emergency department (ED) patients, especially in safety net hospitals, although patients could benefit from specialty care follow-up [1,2]. Although the Patient Protection and Affordable Care Act [3] and professional associations advocate a medical home for all patients [4,5], many safety net hospital patients do not have a primary care provider (PCP) to coordinate care and make referrals [6]. For this reason, patients requiring specialty care services are often overlooked and end up without treatment options until their health advances to an acute stage, placing the patient at risk for ineffective and costly treatment. Referring a patient for follow-up with a PCP, even if one were available, does not provide specialized testing, equipment, or procedures only available via specialty services. Therefore, many ED patients require specialty care referral at the time of their ED visit.

Our study included a broad range of specialists available for ED follow-up care, whereas prior ED follow-up studies typically involve referral to a PCP or primary care clinic to address a specific health condition such as asthma or chest pain. Emergency department referral to follow-up care has generally poor compliance. Prior studies have incorporated some of the following factors that increased the likelihood of keeping an appointment: scheduling a specific appointment date and time before leaving the ED [7-18], removing financial barriers such as payment requirements [13,15,19-22], ED providers perceiving the follow-up as medically necessary [23], and involving follow-up care providers in the referral process [11,22]. Addressing just 1 or 2 of these factors alone during the ED visit has only resulted in a follow-up rate ranging from 14% to 65% [7-11,24-28].

Incorporating all of the above factors associated with ED follow-up to improve appointment compliance has not been successfully accomplished to date. We sought to address ED follow-up barriers simultaneously by developing a specific referral mechanism for patients requiring urgent specialty care follow-up (within 1 month of their ED index visit). Our intervention is unique because the following factors are addressed simultaneously: (1) patients schedule their own specialty care follow-up appointment date and time before leaving the ED; (2) the ED provider determines the need for an urgent follow-up and confirms follow-up urgency in conjunction with a specialist; (3) the specialty service provides point of care input; and (4) payment is not required at the time of the follow-up visit. We also devised the system so that the ED provider’s time and effort are minimal.

The goal of the investigation was to introduce an intervention addressing factors shown to increase compliance with referrals from a safety net hospital ED to specialty services. We hypothesized that patients using our unique referral system would have a better appointment-keeping rate than the historical 62% rate of the general population at our hospital scheduled to those services and than the current literature benchmark rate of 65%.