Steiner A, Robinson R
Institute for Health Policy Studies, University of Southampton, UK.
J Health Serv Res Policy. 1998 Jul;3(3):173-84. doi: 10.1177/135581969800300309.
To review the high quality US evidence on performance of managed health care organisations and the available US evidence on specific managed care techniques; namely, financial incentives, utilisation management and review, physician profiling and disease management.
Literature searches were conducted using numerous databases including Medline, Embase, the Social Sciences Citation Index and the National Health Service (NHS) Centre for Reviews and Dissemination library. For inclusion of evaluations of overall performance, studies had to use a comparison group (typically fee-for-service patients), make appropriate statistical adjustments for differences between groups, and be published in a peer-reviewed journal from 1980 forward. For assessments of techniques, less-demanding inclusion criteria reflected the paucity of generalisable literature; however, more current results were required (1990 forward).
We identified 70 articles for systematic review, covering 18 dimensions of performance (e.g. utilisation, quality of care, consumer satisfaction, equity). The strength of the evidence varied by dimension. It was strongest for utilisation and quality. In general, managed care seems to reduce hospitalisation and use of high-cost discretionary services, to increase preventive screening, and to be neutral in terms of patient outcomes. As for specific techniques, we identified 19 articles for review, but limitations of these studies prevented our drawing any definite conclusions about techniques' effectiveness. This is an important, if somewhat negative, conclusion.
Applying US evidence is complicated by an irrelevant comparator and a higher baseline of utilisation. Managed care brought Americans the familiar NHS practices of population-based health care and resource management through gatekeeping; hence, changes due to UK adoption of managed care techniques may be modest. US evidence should be used to generate hypotheses, not to predict UK behaviour.
回顾关于管理式医疗组织绩效的高质量美国证据，以及关于特定管理式医疗技术的现有美国证据；即财务激励、利用管理与审查、医师档案分析和疾病管理。
使用多个数据库进行文献检索，包括医学索引数据库（Medline）、荷兰医学文摘数据库（Embase）、社会科学引文索引和英国国家医疗服务体系（NHS）综述与传播中心图书馆。对于纳入总体绩效评估的研究，必须使用对照组（通常是按服务收费的患者）进行组间差异的适当统计调整，并发表于1980年以后的同行评审期刊。对于技术评估，要求较低的纳入标准反映了可推广文献的匮乏；然而，需要更新的结果（1990年以后）。
我们确定了70篇文章进行系统综述，涵盖18个绩效维度（如利用率、医疗质量、消费者满意度、公平性）。证据的强度因维度而异。在利用率和质量方面最强。总体而言，管理式医疗似乎减少了住院率和高成本酌情服务的使用，增加了预防性筛查，并且在患者结局方面保持中性。至于特定技术，我们确定了19篇文章进行综述，但这些研究的局限性使我们无法就技术的有效性得出任何明确结论。这是一个重要的结论，尽管有点消极。
应用美国证据因不相关的比较对象和更高的利用基线而变得复杂。管理式医疗通过守门人制度将基于人群的医疗保健和资源管理这一英国人熟悉的做法带给了美国人；因此，英国采用管理式医疗技术带来的变化可能不大。美国证据应用于提出假设，而非预测英国的行为。
