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Locked down or locked out? Trends in psychiatric emergency services utilization during the COVID-19 pandemic. 封锁还是封锁?COVID-19大流行期间精神科急诊服务的使用趋势。
IF 1.9 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2023-04-01 Epub Date: 2022-12-06 DOI: 10.1177/13558196221135119
Alison Duncan, Carolina-Nicole Herrera, Margaret Okobi, Shurobhi Nandi, Rachel Oblath

Objective: To estimate changes in Boston Emergency Services Team (BEST) psychiatric emergency services (PES) encounter volume (total and by care team) and inpatient disposition during the first 8 months of the COVID-19 pandemic.

Methods: Data on 30,657 PES encounters was extracted from the four-county, BEST reporting system. The study period consisted of the first 34 weeks of 2019 and 2020. This period corresponded to the first five stages of Massachusetts's COVID-19 public health restrictions: pre-lockdown, lockdown, Phase I, II and III reopenings. Descriptive and regression analyses were performed to estimate changes in encounter volume by care team and disposition.

Results: Compared to the same period in 2019, covariate-adjusted, weekly PES encounters decreased by 39% (β = -0.40, 95% Confidence Interval (CI) = [-0.51, -0.28], p < 0.00) during the lockdown. PES volume remained significantly lower during Phase I reopening compared to the previous year but returned to 2019 levels during Phase II. The covariate-adjusted proportion of weekly encounters that led to inpatient admission significantly increased by 16% (CI = [0.11, 0.21], p < 0.00) for mobile crisis teams (MCTs) and significantly declined by 13% (CI = [-0.19, -0.07], p < 0.00) for BEST-designated emergency departments during the lockdown period compared to the prior year.

Conclusions: The overall drop in PES utilization and the rise in inpatient admissions for MCT encounters suggests that during the early phases of the pandemic, patients delayed psychiatric care until they had a psychiatric crisis. Public health messaging about the lockdowns and absent equivalent messaging about the availability of telehealth services may have made patients more reluctant to seek psychiatric care.

目的估算在 COVID-19 大流行的前 8 个月中,波士顿急救服务团队(BEST)精神科急救服务(PES)接诊量(总接诊量和护理团队接诊量)和住院病人处置情况的变化:从四个县的 BEST 报告系统中提取了 30,657 次精神科急诊服务的数据。研究期间包括 2019 年和 2020 年的前 34 周。这一时期与马萨诸塞州 COVID-19 公共卫生限制的前五个阶段相对应:封锁前、封锁、第一阶段、第二阶段和第三阶段重新开放。我们进行了描述性分析和回归分析,以估算按护理团队和处置方式划分的就诊量变化:与 2019 年同期相比,在封锁期间,经协变量调整后的每周 PES 就诊量减少了 39%(β = -0.40,95% 置信区间 (CI) = [-0.51, -0.28],p < 0.00)。与前一年相比,第一阶段重新开放期间的 PES 量仍然明显较低,但在第二阶段恢复到了 2019 年的水平。与前一年相比,在封锁期间,流动危机小组(MCT)每周导致住院的就诊比例经协变因素调整后大幅增加了 16% (CI = [0.11, 0.21],p < 0.00),而 BEST 指定急诊部门的就诊比例则大幅下降了 13% (CI = [-0.19, -0.07],p < 0.00):PES使用率的整体下降和MCT住院率的上升表明,在大流行病的早期阶段,患者推迟了精神科治疗,直到出现精神危机。有关封锁的公共卫生信息以及有关远程医疗服务可用性的同等信息的缺失可能使患者更不愿意寻求精神科治疗。
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引用次数: 0
Impact of COVID-19 in mental health trusts. COVID-19对精神卫生信托机构的影响。
IF 2.4 4区 医学 Q2 Medicine Pub Date : 2023-04-01 DOI: 10.1177/13558196221116298
Russell Mannion, Frederick H Konteh, Rowena Jacobs

Objective: To explore how mental health trusts in England adapted and responded to the challenges posed by the COVID-19 pandemic, with the aim of identifying lessons that can be learned during and beyond the pandemic.

Methods: Following a scoping study, we undertook 52 semi-structured interviews with senior managers, clinicians, patient representatives and commissioning staff across four case study sites. These sites varied in size, location and grading awarded by a national regulatory body. We explored how services have been repurposed and reorganized in response to the pandemic and the participants' perceptions of the impact of these changes on quality of care and the wellbeing of staff.

Results: Mental health trusts have shown great flexibility and resilience in rapidly implementing new models of care and developing creative digital solutions at speed. New collaborative arrangements have been stimulated by a shared sense of urgency and enabled by additional funding and a more permissive policy environment. But there has also been a significant negative impact on the wellbeing of staff, particularly those staff from a minority ethnic background. Also, there were concerns that digital technology could effectively disenfranchise some vulnerable groups and exacerbate existing health inequalities.

Conclusions: Many of the service changes and digital innovations undertaken during the pandemic appear promising. Nevertheless, those changes need to be urgently and rigorously appraised to assure their effectiveness and to assess their impact on social exclusion and health inequalities.

目的:探讨英格兰精神卫生信托机构如何适应和应对2019冠状病毒病大流行带来的挑战,以确定在大流行期间和之后可以吸取的教训。方法:根据范围研究,我们对四个案例研究地点的高级管理人员、临床医生、患者代表和委托人员进行了52次半结构化访谈。这些站点在规模、位置和由国家监管机构授予的等级上各不相同。我们探讨了如何调整和重组服务以应对大流行,以及与会者对这些变化对护理质量和工作人员福祉的影响的看法。结果:精神卫生信托在快速实施新的护理模式和快速开发创造性数字解决方案方面显示出极大的灵活性和弹性。共同的紧迫感刺激了新的合作安排,更多的资金和更宽松的政策环境使之成为可能。但这也对员工的福利产生了重大的负面影响,尤其是那些来自少数族裔背景的员工。此外,有人担心,数字技术可能会有效地剥夺一些弱势群体的权利,加剧现有的保健不平等。结论:疫情期间开展的许多服务变革和数字创新似乎大有希望。然而,需要紧急和严格地评价这些变化,以确保其有效性,并评估其对社会排斥和保健不平等的影响。
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引用次数: 5
A new children's hospital with a larger floor space, single rooms, and V-shaped ward design: A pre-post evaluation of nurse time providing patient care and nurse, patient, and family experiences. 一个占地面积更大的新儿童医院,单间,v形病房设计:对护士提供病人护理和护士、病人和家庭体验的前后评估。
IF 2.4 4区 医学 Q2 Medicine Pub Date : 2023-04-01 DOI: 10.1177/13558196221146658
Fenella J Gill, Helen Nelson, Natasha Bear, Mary Tallon, Catherine Pienaar, Jade Ferullo, Sue Baker

Background: The impact of hospital building design on patients, families and nurses related to nursing care interactions is not well understood. This study reports a pre-post intervention study to understand the effects of the move to a new children's hospital in Perth, Australia, on nurse workflow activities and on patient, family, and nurse experiences.

Methods: We used a pre-post explanatory sequential design involving observation of nurse work tasks; measurement of the Practice Environment Scale and Nurse Work Index; weekly surveys of nurse, patient and family experiences; and nurse focus groups and interviews with patients and families. Survey data were analysed using linear regression; qualitative data analysis used a thematic approach.

Results: Nurse time spent walking almost doubled (p < 0.001), from an estimated 10 min at T1 (pre-move) to around 20 min at T4 (12 months post-move), but there was no difference in nurse time providing patient care (p = 0.114). The Practice Environment Scale and Nurse Work Index showed significantly reduced scores for nursing foundations for quality of care (adjusted mean difference -0.08, p = 0.016) and staffing and resource adequacy (adjusted mean difference -0.19, p < 0.001).This fall was mirrored in nurse experience surveys with a reduction in mean scores from T1 to T3 (3 months post-move) of -0.7 (p < 0.001) and from T1 to T4 of -0.4 (p = 0.002). Thematic analysis of qualitative data found that initial challenges appeared to reduce over time. Nurses reported difficulties managing workflow in the new wards and feelings of exhaustion at T3, but this changed to more positive accounts at T4. For patients and families there was a tension between leaving the old and familiar, enjoying the light and space of the new and shared observations that nurses appeared to be busier at T3. At T4, these experiences had changed to 'being a family in hospital' and confidence that a nurse was always close by.

Conclusions: Both benefits and challenges of the new hospital design were encountered from the perspective of nurses, patients, and families. Nurses spent double the time walking in the new environment, but time spent providing patient care was unchanged. Over time, the initial practice challenges reduced as nurses adapted to working in the new environment.

Trial registration: ACTRN12618000775213.

背景:医院建筑设计对患者、家属和护士有关护理互动的影响尚不清楚。本研究报告了一项干预前和干预后的研究,旨在了解搬到澳大利亚珀斯一家新的儿童医院对护士工作流程活动以及患者、家属和护士经验的影响。方法:采用前后解释序贯设计,对护士工作任务进行观察;执业环境量表及护士工作指数的测量;每周对护士、病人和家属的经历进行调查;护士焦点小组和病人及家属的访谈。调查数据采用线性回归分析;定性数据分析采用专题方法。结果:护士走路的时间几乎翻了一番(p < 0.001),从T1(移动前)估计的10分钟到T4(移动后12个月)约20分钟,但护士提供病人护理的时间没有差异(p = 0.114)。执业环境量表和护士工作指数显示护理基础、护理质量(调整平均差值-0.08,p = 0.016)和人员配备和资源充足性(调整平均差值-0.19,p < 0.001)得分显著降低。这种下降反映在护士经验调查中,从T1到T3(迁移后3个月)的平均得分下降了-0.7 (p < 0.001),从T1到T4的平均得分下降了-0.4 (p = 0.002)。对定性数据的专题分析发现,最初的挑战似乎随着时间的推移而减少。护士报告了在新病房管理工作流程的困难和T3的疲惫感,但这在T4转变为更积极的账户。对于病人和家属来说,离开旧的和熟悉的环境,享受新环境的光线和空间,以及共同观察到T3的护士似乎更忙,这两者之间存在紧张关系。在T4,这些经历已经变成了“医院里的一家人”,并且相信护士总是在身边。结论:从护士、患者和家属的角度来看,新医院设计的好处和挑战都遇到了。护士在新环境中行走的时间增加了一倍,但提供病人护理的时间没有变化。随着时间的推移,随着护士适应新环境的工作,最初的实践挑战减少了。试验注册:ACTRN12618000775213。
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引用次数: 1
Creating healthy hospital retail food environments: Multiple pathways to successful at scale policy implementation in Australia. 创建健康的医院零售食品环境:在澳大利亚成功实施大规模政策的多种途径。
IF 2.4 4区 医学 Q2 Medicine Pub Date : 2023-04-01 DOI: 10.1177/13558196221117650
Leonie Cranney, Margaret Thomas, Tarli O'Connell, Renee Moreton, Lucy Corbett, Adrian Bauman, Philayrath Phongsavan

Objective: In 2017, the Australian state of New South Wales introduced a revised policy to provide a healthy food and drink environment for staff and visitors in the state's publicly funded health facilities. We sought to understand how contextual factors, intervention features and the responses of diverse stakeholders affected the policy's implementation in public hospitals.

Methods: Ninety-nine interviews were conducted with chief executives, implementers and retailers in the health and food retail systems after the target date for the implementation of 13 initial policy practices. Stakeholder responses were analysed to understand commitment to, engagement with and achievement of these practices and the different contexts and implementation approaches that prompted these responses.

Results: Key mechanisms that drove systemic change included stakeholders' broad acceptance of the policy premise; stakeholders' sense of accountability and desire for the policy to succeed; and the policy's perceived benefits, feasibility and effectiveness. Important underpinning factors were chief executives' commitment to implementation and monitoring, a flexible approach to locally tailored implementation and historical precedents.

Conclusions: This study provides policy and practice insights for the initial phase of state-wide implementation to achieve change in health facility food retail environments.

目标:2017年,澳大利亚新南威尔士州出台了一项经修订的政策,为该州公共资助的卫生设施的工作人员和访客提供健康的食品和饮料环境。我们试图了解背景因素、干预特征和不同利益相关者的反应如何影响政策在公立医院的实施。方法:在13项初步政策实施的目标日期之后,对卫生和食品零售系统的首席执行官、实施者和零售商进行了99次访谈。分析了利益相关者的反应,以了解对这些实践的承诺、参与和成就,以及促使这些反应的不同背景和实施方法。结果:驱动系统性变革的关键机制包括利益相关者对政策前提的广泛接受;利益相关者的问责意识和对政策成功的渴望;以及政策的感知效益、可行性和有效性。重要的支撑因素是首席执行官对实施和监督的承诺、对因地制宜的实施采取灵活方法以及历史先例。结论:本研究为全国范围内实施的初期阶段提供了政策和实践见解,以实现卫生机构食品零售环境的变化。
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引用次数: 0
Impact of the COVID-19 pandemic on people with disabilities and implications for health services research. COVID-19 大流行对残疾人的影响及对医疗服务研究的启示。
IF 1.9 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2023-04-01 Epub Date: 2023-02-23 DOI: 10.1177/13558196231160047
Divya Goyal, Xanthe Hunt, Hannah Kuper, Tom Shakespeare, Lena Morgon Banks
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引用次数: 0
CORRECTION NOTICE "Family physician services and blood pressure control in China: A population-based retrospective cohort study". 更正通知“中国家庭医生服务和血压控制:一项基于人群的回顾性队列研究”。
IF 2.4 4区 医学 Q2 Medicine Pub Date : 2023-03-13 DOI: 10.1177/13558196231158944
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引用次数: 0
Challenges to the delivery of clinical diabetes services in Ghana created by the COVID-19 pandemic. COVID-19大流行给加纳提供糖尿病临床服务带来的挑战。
IF 2.4 4区 医学 Q2 Medicine Pub Date : 2023-01-01 DOI: 10.1177/13558196221111708
Eunice Twumwaa Tagoe, Justice Nonvignon, Robert van Der Meer, Itamar Megiddo, Brian Godman

Objective: The barriers to delivering clinical non-communicable disease services in low- and middle-income countries have risen with the onset of COVID-19. Using Ghana as a case study, this article examines the changes COVID-19 has brought to diabetes service delivery and considers policy responses to deal with future such outbreaks.

Methods: We conducted 18 interviews between November 2020 and February 2021 with health professionals and administrators from primary, secondary and tertiary facilities within the Ghana Health Service. The analysis was performed using deductive and inductive methods.

Results: There were six general themes in interviewees' responses: (1) COVID-19 had exacerbated the problems of high medicine and service costs and medicine shortages, (2) the pandemic had exacerbated problems of poor patient record keeping, (3) COVID-19 had reduced the availability of suitably trained health providers, (4) staff had become demoralized by management's unwillingness to make innovative changes to cope with the pandemic, (5) COVID-19 led to a reorganization of diabetes services, and (6) the country's national health insurance scheme lacked flexibility in dealing with the pandemic.

Conclusions: Access to resources is limited in LMICs. However, our study highlights practical policy responses that can improve health providers' response to COVID-19 and future pandemics.

目标:随着COVID-19的爆发,在低收入和中等收入国家提供临床非传染性疾病服务的障碍有所增加。本文以加纳为例,探讨了COVID-19给糖尿病服务提供带来的变化,并考虑了应对未来此类疫情的政策对策。方法:我们在2020年11月至2021年2月期间对来自加纳卫生服务机构的初级、二级和三级设施的卫生专业人员和管理人员进行了18次访谈。分析采用演绎和归纳法进行。结果:受访者的回答有六大主题:(1) COVID-19加剧了医疗和服务成本高企和药品短缺的问题,(2)大流行加剧了患者记录保存不良的问题,(3)COVID-19减少了受过适当培训的卫生服务提供者的可用性,(4)由于管理层不愿做出创新变革以应对大流行,工作人员士气低落,(5)COVID-19导致糖尿病服务的重组。(6)该国的国家医疗保险计划在应对疫情方面缺乏灵活性。结论:中低收入国家获得资源的机会有限。然而,我们的研究强调了可以改善卫生服务提供者对COVID-19和未来大流行的反应的实际政策对策。
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引用次数: 3
Engagement of patient and family advisors in health system redesign in Canada. 加拿大卫生系统重新设计中患者和家庭顾问的参与。
IF 2.4 4区 医学 Q2 Medicine Pub Date : 2023-01-01 DOI: 10.1177/13558196221109056
Shannon L Sibbald, Kristina M Kokorelias, Gayathri Embuldeniya, Walter P Wodchis

Objectives: Globally, there has been a shift towards integrated care delivery and patient-centredness in the design of health services. Such a transformation is underway in Ontario, which is progressively using an interprofessional team-based approach known as Ontario Health Teams (OHTs) to deliver care. During their initial development, OHTs were required to integrate patient and families' preferences, experiences and opinions in the form of consultation and partnership with patient and family advisors (PFAs). This study aimed to understand how PFAs were involved in the early stages of planning for health system change and the perceived benefits of including PFAs in system reform.

Methods: This study used a qualitative descriptive design. Semi-structured interviews were conducted with 126 participants at 12 OHTs, including PFA (n = 16) and non-PFA (n = 110) members (e.g. clinicians). Data were analysed thematically.

Results: We identified four themes; mechanisms of engagement, motivations to engage, challenges to PFA engagement and PFAs' impact and added value. Overall, participants viewed PFA engagement positively and PFAs felt valued and empowered. There remain logistical challenges around PFA compensation, and the amount of time and training expected of PFAs. However, all participants believed that developing an understanding of the patient, caregiver and family experience will strengthen the engagement of PFAs in OHT planning, decisions and policies.

Conclusions: Diverse approaches to and stages of PFA engagement fostered meaningful and highly valued contributions to OHT development. These were considered critical to successfully achieving the mandate of patient-centred care reform.

目标:在全球范围内,保健服务的设计已转向综合护理提供和以病人为中心。安大略省正在进行这种转变,逐步采用一种以跨专业团队为基础的方法,即安大略保健小组(OHTs)来提供护理。在最初的发展过程中,oht被要求以咨询和与患者和家庭顾问(PFAs)合作的形式整合患者和家庭的偏好、经验和意见。本研究旨在了解PFAs如何参与卫生系统变革规划的早期阶段,以及将PFAs纳入系统改革的感知效益。方法:本研究采用定性描述设计。在12个OHTs对126名参与者进行了半结构化访谈,包括PFA (n = 16)和非PFA (n = 110)成员(如临床医生)。数据按主题进行分析。结果:我们确定了四个主题;参与机制、参与动机、PFA参与的挑战以及PFA的影响和附加价值。总体而言,参与者积极看待PFA的参与,PFA感到受到重视和授权。在PFA薪酬、PFA所需的时间和培训方面,仍然存在后勤方面的挑战。然而,所有与会者都认为,发展对患者、护理者和家庭经验的理解将加强PFAs在OHT计划、决策和政策中的参与。结论:PFA参与的不同方法和阶段促进了对OHT发展的有意义和高度重视的贡献。这些被认为是成功实现以病人为中心的护理改革任务的关键。
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引用次数: 4
Immigrants' and refugees' experiences of access to health and social services during the COVID-19 pandemic in Toronto, Canada. 加拿大多伦多2019冠状病毒病大流行期间移民和难民获得卫生和社会服务的经历
IF 2.4 4区 医学 Q2 Medicine Pub Date : 2023-01-01 DOI: 10.1177/13558196221109148
Doris Leung, Charlotte Lee, Angel He Wang, Sepali Guruge

Objective: In 2020, the World Health Organization reported that immigrants were the most vulnerable to contracting COVID, due to a confluence of personal and structural barriers. This study explored how immigrants and refugees experienced access to health and social services during the first wave of COVID-19 in Toronto, Canada.

Methods: This study analyzed secondary data from a qualitative study that was conducted between May and September 2020 in Toronto that involved semi-structured interviews with 72 immigrants and refugees from 21 different countries. The secondary data analysis was informed by critical realism.

Results: The vast majority of participants experienced fear and anxiety during the COVID-19 outbreak but through a combination of self-reliance and community support came to terms with the realities of the pandemic. Some even found the lifestyle changes engendered by the pandemic a positive experience.

Conclusions: Self-reliance may hinder help-seeking and augment the threat of COVID-19. This is particularly a concern for the most vulnerable immigrants, who experience multiple disruptions in their health care, have limited material resources and social supports, and perhaps are still dealing with the challenges of settling in the new country.

目标:2020年,世界卫生组织报告称,由于个人和结构性障碍的共同作用,移民最容易感染COVID。本研究探讨了加拿大多伦多第一波COVID-19期间移民和难民如何获得卫生和社会服务。方法:本研究分析了2020年5月至9月在多伦多进行的一项定性研究的二手数据,该研究涉及对来自21个不同国家的72名移民和难民的半结构化访谈。二级数据分析采用批判现实主义。结果:绝大多数参与者在2019冠状病毒病暴发期间经历了恐惧和焦虑,但通过自力更生和社区支持的结合,他们最终接受了大流行的现实。有些人甚至认为,疫情造成的生活方式改变是一种积极的经历。结论:自力更生可能会阻碍寻求帮助并增加COVID-19的威胁。对于最脆弱的移民来说,这尤其令人担忧,因为他们的保健服务多次中断,物质资源和社会支持有限,而且可能仍在应对在新国家定居的挑战。
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引用次数: 3
Readmission trends before and after a national reconfiguration of emergency departments in Denmark. 丹麦急诊科重组前后的再入院趋势。
IF 2.4 4区 医学 Q2 Medicine Pub Date : 2023-01-01 DOI: 10.1177/13558196221108894
Søren Bie Bogh, Marianne Fløjstrup, Sören Möller, Mickael Bech, Annmarie T Lassen, Mikkel Brabrand, Christian B Mogensen

Objective: In order to achieve better and more efficient emergency health care, the Danish public hospital system has been reconfigured, with hospital emergency care being centralised into extensive and specialised emergency departments. This article examines how this reconfiguration has affected patient readmission rates.

Methods: We included all unplanned hospital admissions (aged ≥18 years) at public, non-psychiatric hospitals in four geographical regions in Denmark between 1 January 2007 and 24 December 2017. Using an interrupted time-series design, we examined trend changes in the readmission rates. In addition to analysing the overall effect, analyses stratified according to admission time of day and weekdays/weekends were conducted. The analyses were adjusted for patient characteristics and other system changes.

Results: The seven-day readmission rate increased from 2.6% in 2007 to 3.8% in 2017, and the 30-day rate increased from 8.1% to 11.5%. However, the rates were less than what they would have been had the reconfiguration not been introduced. The reconfiguration reduced the seven-day readmission rate by 1.4% annually (hazard ratio [CI 95%] 0.986 [0.981-0.991]) and the 30-day rate by 1% annually (hazard ratio [CI 95%] 0.99 [0.987-0.993]).

Conclusions: Reconfiguration reduced the rate of increase in readmissions, but nevertheless readmissions still increased across the study period. It seems hospitals and policymakers will need to identify further ways to reduce patient loads.

目的:为了实现更好和更有效的紧急医疗保健,丹麦公立医院系统进行了重新配置,将医院紧急护理集中到广泛和专门的急诊科。本文研究了这种重新配置如何影响患者再入院率。方法:我们纳入了2007年1月1日至2017年12月24日在丹麦四个地理区域的公立非精神病院的所有计划外住院患者(年龄≥18岁)。使用中断时间序列设计,我们检查了再入院率的趋势变化。在分析整体效果的基础上,根据入院时间、工作日/周末进行分层分析。根据患者特征和其他系统变化对分析结果进行了调整。结果:7天再入院率从2007年的2.6%上升至2017年的3.8%,30天再入院率从8.1%上升至11.5%。然而,这一比率比没有进行重新配置时的比率要低。重新配置使7天再入院率每年降低1.4%(风险比[CI 95%] 0.986[0.981-0.991]), 30天再入院率每年降低1%(风险比[CI 95%] 0.99[0.987-0.993])。结论:重构降低了再入院率,但在整个研究期间再入院率仍在增加。医院和政策制定者似乎需要找到进一步减少病人负担的方法。
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引用次数: 1
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