ISQUA17-3302THE ASSOCIATION BETWEEN HOSPITAL–COMMUNITY CONTINUITY OF CARE PATIENTS WITH CHRONIC DISEASE AND CLINICAL OUTCOMES

Abstract

Objectives: Transition of the patient from one physician to another throughout the therapeutic process; particularly in the transition from hospital to community, is a known weak point in the provision of safe, high quality care. The phenomenon is more prominent in patients with chronic illnesses, in light of the fact that these patients are usually receiving numerous medications and that their care is more fragmented. These patients therefore require closer supervision in disease management. Efforts are being made in Israel by the Health Funds to improve the maintenance of continuous treatment. The goals of this study were to evaluate the level of care continuity in chronic disease patients from four Health Funds, hospitalized at one medical center. Second, we have set out to learn about the association between maintaining continuity and clinical outcomes. Method(s): Enlistment of patients with chronic obstructive pulmonary diseases (COPD) or congestive heart failure (CHF), who had been hospitalized in the Department of Internal Medicine at Sheba Medical Center, due to worsening of their disease. During hospitalization, information was collected regarding patient admission, co-morbidities and socio-economic factors. Subsequently, information was collected regarding patient discharge. Telephone interviews were conducted with patients three months after discharge, to gather details about maintenance of discharge recommendations. Finally, patient charts (in the community) were reviewed by the research team, with the goal of confirming file updating and references to discharge recommendations. Result(s): 632 patients were enlisted; 220 with COPD and 401 with CHF; average age was 11.3 +/- 74.9. Of this group, 28.1% had a readmission within one month; 5.4% deceased within one month; 12% deceased within three months. The information gathered from all patient files led to the formulation of an index that reflects the extent of continuity maintenance (maximal score 6). The average score amongst participants in this study was 1.7 +/- 3.5. No significant difference was found in this score between the various Health Funds. Logistic regression found the index to be an explicit factor protecting against mortality within one month (OR = 0.61; CI = 0.50-0.75); mortality within three months (OR = 0.73; CI = 0.63-0.84(; and readmissions within one month (OR = 0.81; CI = 0.73-0.90). Conclusion(s): This study found that maintenance of continuity of care in Israel requires improvement. Attempts made by the Health Funds to improve processes, did not show differences between the various funds. We have found a clear association between the level of continuity of care and patient outcomes. We thus assume that improvement in continuity of care will lead to improvement in outcomes, such as repeat hospitalizations and mortality.