RESUMO
Objective: To evaluate the effectiveness of a 24-hour telephone access outpatient clinic (24-hour access clinic) in terms of healthcare utilisation and mortality in patients with five chronic conditions (chronic obstructive pulmonary disease, atrial fibrillation/flutter, congestive heart failure, inflammatory bowel disease and chronic liver disease). Methods and analysis: This was a registry-based controlled cohort study. The 24-hour access clinic was established at Silkeborg Regional Hospital in Central Denmark Region. The five other regional hospitals served as comparison hospitals. The 24-hour access clinic allowed patients with five chronic conditions with ongoing hospital outpatient follow-up to call the hospital outpatient clinic in case of an exacerbation. Outcomes were use of hospital admissions, length of stay (LOS), outpatient visits, contacts to general practice and all-cause mortality during 18 months of follow-up. Results: The study included 992 the 24-hour access patients and 3878 usual care patients. For the five conditions combined, the 24 hours access patients had fewer all-cause admissions (incidence rate ratio (IRR) 0.81, 95% Cl 0.71 to 0.92), general practice out-of-hours contacts (IRR 0.81, 95% C 0.71 to.92) and shorter LOS (IRR 0.71, 95% CI 0.57 to 0.88). The rate of all-cause outpatient visits tended to be higher (IRR 1.07, 95% CI 0.99 to 1.15). General practice daytime contacts were similar between the groups, and there was no significant difference in mortality. Conclusions: The results suggest that a 24-hour telephone access clinic may lead to enhanced integration of care measured as unplanned acute care substituted with planned outpatient care.
RESUMO
BACKGROUND: The complexity of caring for patients with chronic conditions necessitates new models of integrated care to accommodate an increasing demand. To inform the development of integrated care models, it is essential to map patients' use of healthcare resources. In this nationwide registry-based cohort study, we describe and compare patient characteristics and healthcare utilisation between Danish patients with chronic conditions in general practice follow-up and in hospital outpatient follow-up. METHODS: On 1 January 2016, we identified 250,402 patients registered in 2006-2015 with a hospital diagnosis of atrial fibrillation/flutter, congestive heart failure, chronic liver disease, inflammatory bowel disease or chronic obstructive pulmonary disease. By linkage to national social and health registries, patient characteristics and 12-month healthcare utilisation were extracted. Incidence rates of health care utilisation were compared between patients with chronic conditions in general practice follow-up and patients in hospital outpatient follow-up using negative binomial regression. RESULTS: Across all five conditions, the largest proportions of patients were in general practice follow-up (range = 59-87%). Patients in hospital outpatient follow-up had higher rates of exacerbation-related admissions (adjusted incidence rate ratio (IRR) range = 1.3 to 2.8) and total length of stay (IRR range = 1.2 to 2.2). For these five conditions, all-cause admissions and lengths of stay, general practice daytime and out-of-hours contacts, and municipal home nursing contacts were similar between follow-up groups or higher among patients in general practice follow-up. The exception was patients with chronic obstructive pulmonary disease, where patients in hospital outpatient follow-up had higher utilisation of healthcare resources. CONCLUSIONS: Patients in general practice follow-up accounted for the largest proportion of total healthcare utilisation, but patients in hospital outpatient follow-up were characterised by high exacerbation rates. Enhanced integration of chronic care may be of most benefit if patients in general practice follow-up are targeted, but it is also likely to have an impact on exacerbation rates among patients in hospital outpatient follow-up.