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The impact of physician training level on emergency readmissions within internal medicine
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
2004 (English)In: International Journal of Technology Assessment in Health Care, ISSN 0266-4623, E-ISSN 1471-6348, Vol. 20, no 4, 516-23 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: The research question was whether training level of admitting physicians and referrals from practitioners in primary health care (PHC) are risk factors for emergency readmission within 30 days to internal medicine.

Methods: This report is a prospective multicenter study carried out during 1 month in 1997 in seven departments of internal medicine in the County of Stockholm, Sweden. Two of the units were at university hospitals, three at county hospitals and two in district hospitals. The study area is metropolitan–suburban with 1,762,924 residents. Data were analyzed by multiple logistic regression.

Results: A total of 5,131 admissions, thereby 408 unplanned readmissions (8 percent) were registered (69.8 percent of 7,348 true inpatient episodes). The risk of emergency readmission increased with patient's age and independently 1.40 times (95 percent confidence interval [CI], 1.13–1.74) when residents decided on hospitalization. Congestive heart failure as primary or comorbid condition was the main reason for unplanned readmission. Referrals from PHC were associated with risk decrease (odds ratio, 0.53; 95 percent CI, 0.38–0.73).

Conclusion: The causes of unplanned hospital readmissions are mixed. Patient contact with primary health care appears to reduce the recurrence. In addition to the diagnoses of cardiac failure, training level of admitting physicians in emergency departments was an independent risk factor for early readmission. Our conclusion is that it is cost-effective to have all decisions on admission to hospital care confirmed by senior doctors. Inappropriate selection of patients to inpatient care contributes to poor patient outcomes and reduces cost-effectiveness and quality of care.

Place, publisher, year, edition, pages
2004. Vol. 20, no 4, 516-23 p.
Keyword [en]
Emergency readmission; Clinical experience; Training level; Internal medicine; Referrals.
Identifiers
URN: urn:nbn:se:uu:diva-91358DOI: 10.1017/S0266462304001448OAI: oai:DiVA.org:uu-91358DiVA: diva2:164061
Available from: 2004-02-13 Created: 2004-02-13 Last updated: 2017-12-14Bibliographically approved
In thesis
1. Påverkan av organisatoriska och miljömässiga faktorer på tillgänglighet till akutsjukvården
Open this publication in new window or tab >>Påverkan av organisatoriska och miljömässiga faktorer på tillgänglighet till akutsjukvården
2004 (Swedish)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[en]
The impact of organisational and environmental factors on access to emergency care
Abstract [en]

The settings investigated were departments of internal medicine (IM), orthopaedics and surgery in acute care hospitals in Sweden. The objective was to identify exogenous and endogenous determinants of accessibility of health care. Both qualitative and quantitative analysis of utilisation was performed on national and regional level of data aggregation. The study proposes that accessibility to acute health services is influenced by exogenous factors, partly outside the control of health care professionals, such as season, physical proximity and overall supply. Organisational properties such as availability of inpatient beds, hospital and physician specialisation and the degree of system integration between provides of emergency care have effects on the quality of care. The novel finding is the strong association between acute readmissions and remaining inpatient utilisation indicating effects of bed supply on global use within IM. These conclusions follow:

§ structural changes on system level work as a method of prioritisation between patient groups by changes in criteria of accessibility;

§ the natural and organisational environments determine waiting times in EDs in hospitals by fluctuations of demand;

§ geographical accessibility coincides with the supply in terms of over- or underutilisation mirrored in the outcome of medical care;

§ effective access is determined by the divide of resources between inpatient and outpatient care and the total supply of inpatient care;

§ increasing demands on inpatient care in IM may be derived from deficiencies in the care of chronically ill, elderly patients;

§ transition of information and communication among care givers and patients varies in efficiency depending on vehicles for coordination and system integration;

§ the level of training of the admitting physician has effects on effective accessibility to inpatient care.

There are conflicts between accessibility, efficiency and appropriateness of settings calling for attention to capacity to benefit in addition to needs as priority criteria.

Abstract [sv]

De studerade enheterna var kliniker för internmedicin, ortopedi och kirurgi vid akutsjukhus i Sverige. Studiernas syfte var att identifiera exogena och endogena determinanter av tillgänglighet till sjukvården. Kvalitativa och kvantitativa analyser av vårdutnyttjande utfördes på nationell och regional nivå av dataaggregering. Studierna utmynnar i slutsatsen att tillgängligheten till akutsjukvården påverkas av exogena faktorer, delvis utanför kontrollen för de professionella inom sjukvården, såsom säsong, fysiskt avstånd och totalt utbud. Organisatoriska egenskaper som tillgången till vårdplatser, sjukhusens och läkarnas specialisering och graden av systemintegration mellan producenter av akutvård har effekter på vårdens kvalitet. Det nya fyndet utgörs av upptäckten av en stark association mellan akuta återinskrivningar och övriga inskrivningar. Sambandet indikerar effekterna av vårdplatsutbudet på totalt slutenvårdsutnyttjande inom internmedicinen. Slutsatserna är som följer:

§ strukturell förändring på systemnivå fungerar som metod för prioritering mellan patientgrupper genom förändrad tillgänglighet;

§ den naturliga och den organisatoriska miljön determinerar servicekvaliteten på akutmottagningar vid sjukhusen och tillgängligheten till det akuta vårdutnyttjandet genom fluktuationer i efterfrågan;

§ den geografiska tillgängligheten samvarierar med utbudet, dvs. överutnyttjandet eller underutnyttjandet som återspeglas i medicinskt utfall;

§ vårdsystemets utfall mätt som akuta återinskrivningar i sluten vård inom internmedicinen (effektiv tillgänglighet) beror på distributionen av vårdens resurser, framförallt fördelningen mellan sluten och poliklinisk vård och det totala utbudet av slutenvårdsplatser;

§ den ökande efterfrågan på akut omhändertagande inom internmedicinen kan härledas till problem i vården av kroniskt sjuka, äldre patienter;

§ informationsöverföring och kommunikation mellan vårdgivare och med patienter varierar i effektivitet beroende på samordning och mekanismer för systemintegration;

§ effektiv tillgänglighet till och ändamålsenlighet i den slutna internmedicinska vården påverkas av läkarnas specialisering.

Det finns uppenbara konflikter mellan tillgänglighet, produktivitet och vårdgivarens ändamålsenlighet. Det fordras större uppmärksamhet på kapaciteten att tillgodogöra sig behandling utöver behov som ett kriterium för prioritering mellan patientgrupper.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2004. 95 p.
Series
Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 0282-7476 ; 1324
Keyword
Health services research, access, emergency care, system integration, waiting times, readmission, care outcomes, healthcare organisation, efficiency, appropriateness, Hälso- och sjukvårdsforskning
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:uu:diva-3997 (URN)91-554-5873-4 (ISBN)
Public defence
2004-03-01, Grönwallsalen, Akademiska Sjukhuset, Ingång 70, Uppsala, 13:00
Opponent
Supervisors
Available from: 2004-02-13 Created: 2004-02-13 Last updated: 2014-05-13Bibliographically approved

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