PDF(Pubmed)
Abstract：
Currently, exchange of information between the geriatric clinic and the attending general practitioner (GP) occurs primarily through the doctor\'s letter after discharging from the clinic. The aim of our study was to reduce readmissions of multimorbid, geriatric patients to the clinic by establishing a new form of care via an electronic case file (ECF) and a consultation service (CS). The discharging geriatric clinic filled out an online ECF. The patient\'s GP should document quarterly follow-ups in the ECF. The case file was monitored by the discharging clinic due to a consultation service. The primary efficacy endpoint was the rehospitalization rate within one year. The hospitalization rate for patients managed in the project was 83.1/100 person years (PY), while the control group from insurance data had a rate of 69.0/100 PY. The primary endpoint did not show a statistically significant difference (p = 0.15). A total of 195 contacts were documented via CS for 171 participants, mostly initiated by the clinics. The clinical queries primarily concerned drug therapy. The Covid pandemic had an overall impact on hospitalizations. There are many approaches to reducing hospital readmissions after discharge of older patients. Supporting the transition from inpatient to outpatient care by different professional groups or care systems has been shown to have a positive effect. Furthermore, the utilisation of an ECF can also be beneficial in this regard.
摘要：
目前,老年诊所和主治全科医生（GP）之间的信息交流主要是通过医生在出院后的来信进行的。我们研究的目的是减少多人群的再入院率，通过电子病例档案（ECF）和咨询服务（CS）建立新的护理形式，将老年患者带到诊所。出院的老年病诊所填写了在线ECF。患者的全科医生应在ECF中记录季度随访。由于提供咨询服务，出院诊所对案件档案进行了监控。主要疗效终点是一年内的再住院率。项目中管理的患者住院率为83.1/100人年（PY），而对照组的保险数据为69.0/100PY。主要终点没有显示统计学上的显著差异(p=0.15)。通过CS记录了171名参与者的195名联系人，主要由诊所发起。临床查询主要涉及药物治疗。Covid大流行对住院产生了整体影响。有许多方法可以减少老年患者出院后再入院。由不同的专业团体或护理系统支持从住院到门诊护理的过渡已被证明具有积极的作用。此外，在这方面,ECF的利用也可以是有益的。
