Feldman S R, Fleischer A B, Chen J G
Westwood-Squibb Center for Dermatology Research and the Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1071, USA.
J Am Acad Dermatol. 1999 Mar;40(3):426-32. doi: 10.1016/s0190-9622(99)70492-5.
Gatekeeper-paradigm managed care systems may discourage the use of dermatologists in the management of skin conditions by limiting direct access. This may limit the quality of care patients with skin disorders receive and may be an inefficient use of medical resources.
The purpose of this study was to determine the likelihood that patients with dermatologic conditions who see a primary care provider will be referred to a dermatologist.
Data on the disposition of outpatient visits to primary care physicians for one and only one dermatologic diagnosis were obtained from the 1990-1994 National Ambulatory Medical Care Survey. These data were used in an econometric model to estimate the likelihood of referral to a dermatologist for an episode of care.
Of all visits for a single dermatologic diagnosis, 39% were to primary care physicians. The disposition of referral was more common for these dermatology-related visits than for all office visits to primary care physicians (5.8% vs 4.5%, P < .001). The most frequent diagnoses associated with referral were common dermatologic problems, not rare disorders. The number of visits per episode of care was highly dependent on the assumptions of the analysis, resulting in estimate ranges for referral rates per episode between 6.8% and 18.5% for pediatricians, 8.2% and 23% for family and general practitioners, and 16.6% and 46.5% for internists.
The relative difficulty for primary care providers of managing skin problems is reflected by their frequent need to refer patients with common skin problems and by the greater likelihood of referral for skin disorders than for other medical conditions. The high rates of referral per episode of care supports the cost-effectiveness of direct access to dermatologists.
守门人模式的管理式医疗系统可能会通过限制直接就诊机会，抑制皮肤科医生在皮肤病管理中的使用。这可能会限制皮肤病患者所接受护理的质量，并且可能导致医疗资源的低效利用。
本研究的目的是确定看初级保健医生的皮肤病患者被转诊至皮肤科医生的可能性。
从1990 - 1994年国家门诊医疗调查中获取了仅针对一种皮肤病诊断的初级保健医生门诊处置数据。这些数据被用于一个计量经济学模型，以估计一次就诊被转诊至皮肤科医生的可能性。
在所有针对单一皮肤病诊断的就诊中，39%是看初级保健医生。与这些皮肤科相关就诊相比，转诊处置在所有初级保健医生的门诊就诊中更为常见（5.8%对4.5%，P <.001）。与转诊相关的最常见诊断是常见的皮肤问题，而非罕见疾病。每次就诊的次数高度依赖于分析的假设，导致儿科医生每次就诊转诊率的估计范围在6.8%至18.5%之间，家庭和全科医生为8.2%至23%，内科医生为16.6%至46.5%。
初级保健医生在管理皮肤问题方面相对困难，这体现在他们经常需要转诊常见皮肤问题患者，以及皮肤病转诊的可能性高于其他医疗状况。每次就诊的高转诊率支持了直接就诊皮肤科医生的成本效益。
