Treatment fragmentation between hospitals and the community can result in catastrophic outcomes; uninterrupted treatment with anticoagulant and platelet aggregation inhibitors is particularly important. We assessed the proportion and characteristics of patients who did not visit their primary community-based physician within 1 week of discharge from our department of cardiovascular medicine and the proportion that failed to procure essential drugs at the community pharmacy. We prospectively studied 423 patients who were discharged from our department. They were provided detailed explanations, tablets for 7 days, prescriptions, and a printed drug plan. We traced the time from discharge until a visit with a primary community-based physician, and the time until the procurement of medications, using our computerized community–hospital–integrated system. Complete data were available for 313 patients, of whom 220 were treated with anticoagulants or platelet aggregation inhibitors. For 175 patients, these drugs were initiated during index hospitalizations. Only 1 patient did not receive platelet aggregation inhibitors despite recommendations. Seventy-nine patients (25%) first visited their primary care physicians more than 1 week after discharge. Predictors for delayed visits were living alone (hazard ratio 1.91) and having an in-house caregiver (hazard ratio 2.01). In conclusion, all but 1 patient continued drug therapy after discharge from the hospital. The simple predischarge steps included patient education and provision of a 1-week supply of tablets and prescriptions. Treatment continuation was independent of visits to the community-based primary physician. Patients living alone or with an in-house caregiver more often delayed visits to primary physicians yet continued relevant drug therapy.

医院和社区之间的治疗分散可能会导致灾难性的后果；不间断地使用抗凝剂和血小板聚集抑制剂治疗尤为重要。我们评估了从心血管内科出院后 1 周内没有去看主要社区医生的患者的比例和特征，以及未能在社区药房购买基本药物的患者的比例。我们前瞻性地研究了 423 名从我们科室出院的患者。他们获得了详细的解释、7 天的药片、处方和打印的药物计划。我们使用我们的计算机化社区医院集成系统追踪了从出院到与主要社区医生就诊的时间，以及到采购药物的时间。313 名患者的完整数据可用，其中 220 名接受抗凝剂或血小板聚集抑制剂治疗。对于 175 名患者，这些药物是在初次住院期间开始使用的。尽管有建议，但只有 1 名患者没有接受血小板聚集抑制剂治疗。79 名患者 (25%) 在出院 1 周多后首次去看初级保健医生。延迟就诊的预测因素是独居（风险比 1.91）和有内部护理人员（风险比 2.01）。总之，除 1 名患者外，所有患者出院后均继续药物治疗。简单的出院前步骤包括患者教育和提供 1 周的药片和处方。治疗的继续与否与社区主治医生的就诊无关。独居或与内部护理人员同住的患者往往会推迟去看初级医生，但仍继续相关的药物治疗。