Roberts E, Mays N
King's Fund, London, UK.
Health Policy. 1998 Jun;44(3):191-214. doi: 10.1016/s0168-8510(98)00021-9.
This systematic review assesses the extent to which primary-secondary substitution is possible in the field of emergency care where the range of options for the delivery of care is increasing in the UK and elsewhere. Thirty-four studies were located which met the review inclusion criteria, covering a range of interventions. This evidence suggested that broadening access to primary care and introducing user charges or other barriers to the hospital accident and emergency (A & E) department can reduce demand for expensive secondary care, although the relative cost-effectiveness of these interventions remains unclear. On a smaller scale, employing primary care professionals in the hospital A & E department to treat patients attending with minor illness or injury seems to be a cost-effective method of substituting primary for secondary care resources. Interventions that addressed both sides of the primary-secondary interface and recognised the importance of patient preferences in the largely demand-driven emergency service were more likely to succeed in complementing rather than duplicating existing services. The evidence on other interventions such as telephone triage, minor injuries units and general practitioner out of hours co-operatives was sparse despite the fact that these interventions are growing rapidly in the UK. Quantifying the scope for substitution in any one health system is difficult since the evidence comes from international research studies undertaken in a variety of very different health settings. Simply transferring interventions which succeed in one setting without understanding the underlying process of change is likely to result in unexpected consequences locally. Nevertheless, the review findings clearly demonstrate that shifting the balance of care is possible. It also highlights a persistent gap in professional and lay perceptions of appropriate sources of care for minor illness and injury.
本系统评价评估了在英国及其他地区急诊护理领域，一级护理与二级护理相互替代的可行性，目前该领域的护理服务选择范围正在不断扩大。共检索到34项符合评价纳入标准的研究，涵盖一系列干预措施。这些证据表明，扩大初级护理的可及性，并对医院急诊科引入用户收费或设置其他障碍，可以减少对昂贵二级护理的需求，尽管这些干预措施的相对成本效益仍不明确。在较小规模上，在医院急诊科聘用初级护理专业人员来治疗轻症或轻伤患者，似乎是一种用初级护理替代二级护理资源的经济有效方法。那些兼顾一级护理与二级护理衔接双方，并认识到在以需求为主导的急诊服务中患者偏好重要性的干预措施，更有可能成功地补充而非重复现有服务。尽管电话分诊、轻伤处理单元和全科医生非工作时间合作组织等干预措施在英国迅速发展，但关于它们的证据却很少。由于证据来自在各种截然不同的卫生环境中开展的国际研究，因此量化任何一个卫生系统中的替代范围都很困难。在不了解变革潜在过程的情况下，简单照搬在一种环境中成功的干预措施，可能会在当地导致意想不到的后果。尽管如此，评价结果清楚地表明，改变护理平衡是可行的。它还凸显了专业人员和普通民众在对轻症和轻伤适当护理来源的认知上一直存在差距。
