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Evaluating the Effect of Primary Care Clinic Visits on Survival for Hospitalization

Lee M, Wang MM, Yano EM, Rubenstein LV. Evaluating the Effect of Primary Care Clinic Visits on Survival for Hospitalization. Paper presented at: VA HSR&D National Meeting; 1999 Feb 24; Washington, DC.


Objectives: Objective: From an examination of patients hospitalized at the Sepulveda and West Los Angeles VA Medical Centers, we evaluated the possibility that more frequent primary care users had a greater likelihood of surviving a hospital stay for one of a set of significant clinical situations. Methods: Method: All patients hospitalized during the 1993 fiscal year at Sepulveda VA (SVA) and the West Los Angeles VA (WVA) (two academically-affiliated VA medical centers with active primary care programs in Southern California) were identified. The subset of individuals identified as being admitted for major cardiac, cerebrovascular and respiratory conditions based on ICD-9 codes were specifically utilized in this study, as these conditions appeared to be the most likely to be affected by frequent primary care. We classified each case according to whether the patient survived (survivors), died in hospital or within thirty days of discharge (early death), or died between thirty days and one year after discharge (late death). We obtained demographic information and the mean number of primary care clinic visits during the twelve months prior to hospitalization for patients in each of these three categories. We used a polytomous logistic regression model to determine whether there was a relationship between primary care visitation and survival after adjustment for key independent survival indicators such as age. We also utilized a Cox proportional hazards regression model to examine the same variables as a function of the actual survival time (potentially censored twelve months after hospital discharge). Initial univariate analyses were considered to compare the three study groupings with respect to mean primary care visitation (using the Kruskal-Wallis test). Results: The SVA sample included 3,459 inpatients (88.8% survived, 5.9% late deaths, 5.3% early deaths) and the WVA sample had 5,344 individuals (87.4% survived, 6.2% late deaths, 6.4% early deaths). On a univariate basis, both institutions' survivors had significantly more primary care visits (average 6.7/yr: SVA, 5.3/yr: WVA) than early death (5.1/yr:SVA, 2.7/yr:WLA) or late death (4.1/yr:SVA, 2.7/yr:WLA) patients.This significance held up in both multivariate models. Conclusions: Patients admitted with serious major medical conditions who had been seen more often in primary care clinics prior to their hospitalization were more likely to survive their hospital stay. The significance of the primary care visitation pattern may be to hospitalize the patient earlier in the course of an illness episode or result in better peri-hospital management. It is also possible that the more frequent users had different casemix characteristics than less frequent users, although we did attempt to adjust for many of these potential covariates. At the very least, investigators evaluating the significance of primary care should consider visit patterns into consideration. Impact: With the emphasis in the VA healthcare system on the delivery of primary care, this study suggests that such care may have a direct impact on future hospitalization survival. This provides further impetus for the continuing efforts to adequately deliver this care

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