| Summary: | 博士 === 國立陽明大學 === 衛生福利研究所 === 103 === Background: Avoidable hospitalizations, defined as conditions for which timely and appropriate ambulatory care can reduce the likelihood of future hospitalization, have been applied to assess the access, quality, and performance of ambulatory care. Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Although COPD cannot be completely cured, the Global Initia-tive for Chronic Obstructive Lung Disease recommends that regular and continual medication and appropriate disease management can reduce the symptoms and fre-quency of exacerbations and improve the quality of life in COPD patients. Continuity of care (COC) is considered an essential element of primary care and refers to the ongoing therapeutic relationship between a patient and care provider. Previous studies have suggested that chronic patients with better COC are associated with less health care utilization and more effective chronic disease control. However, the duration of COC that enables an improved outcome remains undetermined.
Objectives: This study had four aims: (1) to determine the relationship between COC and the risk of avoidable hospitalizations in COPD patients; (2) to ascertain whether the estimated period of COC is associated with the risk of avoidable hospitalizations; (3) to explore the effect of having a regular physician on the risk of avoidable hospi-talizations; and (4) to explore the determinants of COC.
Methods: This study adopted a retrospective cohort study design. Data were mainly obtained from the Longitudinal Health Insurance Database 2005 (LHID2005) main-tained by the National Health Research Institute in Taiwan. The study participants comprised incident patients with a confirmed COPD diagnosis received during Janu-ary 1, 2006 to December 31, 2006. According to our study purposes, we used two methods to evaluate the relationship between COC and health outcome. First, to in-vestigate the effect of short-term COC and long-term COC on the risk of avoidable hospitalizations, using the sample group (N = 2,199), we measured two periods of COC and assessed the health outcome of patients in the following year. Second, to understand the effect of having a regular physician on the risk of avoidable hospitali-zations, using the same sample group (N = 1,064), we assessed the first and second year of COC, determining whether patients had a regular physician continually. After measuring the COC, we assessed the health outcomes of patients in the third year. A logistic regression model was used to estimate the adjusted odds ratios (adjusted ORs) of avoidable hospitalizations, and the 95% confidence intervals (95% CIs) associated with COC after other covariates were controlled for. Furthermore, a multinomial lo-gistic regression was used to analyze the determinants of COC. All analyses were conducted using SPSS 12.0 and SAS 9.2.
Results: The logistic regression model revealed that in the short-term COC model, after covariates were controlled for and the high COC group was used as a reference, patients in the low and median COC groups were more likely to undergo COPD-related avoidable hospitalizations. However, only the results of the median COC group were statistically significant (adjusted OR, 1.89; 95% CI, 1.07-3.33). In the long-term COC model, after controlling for covariates and using the high COC group was used as a reference, we determined that patients in the low and median COC groups were more likely to undergo COPD-related avoidable hospitalizations. The adjusted ORs for avoidable hospitalizations in the low and median COC groups were 1.98 (95% CI, 1.00-3.94) and 2.03 (95% CI, 1.05-3.94), respectively. Addition-ally, when having a regular physician for 2 years was used as a reference, patients in the other three groups (first year without a regular physician, second year without a regular physician, and two years without a regular physician) were more likely to un-dergo avoidable hospitalizations. After we controlled for other variables and used the high COC group as reference, the multinomial logistic regression model revealed that patients who were male, older, of low-income status, and with many COPD-related ED visits were more likely to be in the low COC group.
Conclusions: COPD patients with a higher continuity of care had a significantly low-er likelihood of avoidable hospitalizations, and long-term COC exerted a greater ef-fect on reducing the risk of avoidable hospitalizations. Additionally, the first year after initial diagnosis was critical. High COC in the first year protected against avoidable hospitalizations. Moreover, the characteristics of COPD patients with lower COC were the male sex, an older age, a low socioeconomic status, and poor health. Ac-cording to our results, we suggest that policy stakeholders increase financial incentives for encouraging doctors to continually follow-up on patient conditions, a practice that would enhance the patient–physician relationship. Furthermore, particularly for men, older people, people with a low socioeconomic status, and people with poor health, health authorities should promote the importance of COC to motivate people to regularly visit a physician. Finally, health care providers should provide more dis-ease-related education to improve the disease awareness of patients with an initial COPD diagnosis.
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