Kerr E A, Hays R D, Mitchinson A, Lee M, Siu A L
Center for Practice Management and Outcomes Research, VA Medical Center, Ann Arbor, Mich., USA.
J Gen Intern Med. 1999 May;14(5):287-96. doi: 10.1046/j.1525-1497.1999.00336.x.
To examine the influence of utilization review and denial of specialty referrals on patient satisfaction with overall medical care, willingness to recommend one's physician group to a friend, and desire to disenroll from the health plan.
Two cross-sectional questionnaires: one of physician groups and one of patient satisfaction.
Eighty-eight capitated physician groups in California.
Participants were 11,710 patients enrolled in a large California network-model HMO in 1993 who received care in one of the 88 physician groups.
Our main measures were how groups conducted utilization review for specialty referrals and tests, patient-reported denial of specialty referrals, and patient satisfaction with overall medical care. Patients in groups that required preauthorization for access to many types of specialists were significantly (p </=.001) less satisfied than patients in groups that had few preauthorization requirements, even after adjusting for patient and other group characteristics. Patients who had wanted to see a specialist in the previous year but did not see one were significantly less satisfied than those who had wanted to see a specialist and actually saw one (p <.001). In addition, patients who did not see a specialist when desired were more likely to want to disenroll from the health plan than patients who saw the specialist (40% vs 18%, p </=.001) and more likely not to recommend their group to a friend (38% vs 13%, p </=.001).
Policies that limited direct access to specialists, and especially denial of patient-desired referrals, were associated with significantly lower patient satisfaction, increased desire to disenroll, and lower likelihood of recommending the group to a friend. Health plans and physician groups need to take these factors into account when designing strategies to reduce specialty care use.
探讨利用审查和专科转诊拒绝情况对患者对整体医疗护理的满意度、向朋友推荐自己医生团队的意愿以及退出健康计划的愿望的影响。
两份横断面调查问卷：一份针对医生团队，一份针对患者满意度。
加利福尼亚州的88个按人头付费的医生团队。
参与者为1993年在加利福尼亚州一个大型网络模式健康维护组织（HMO）注册的11710名患者，他们在88个医生团队中的一个接受治疗。
我们的主要测量指标包括各团队对专科转诊和检查进行利用审查的方式、患者报告的专科转诊被拒绝情况以及患者对整体医疗护理的满意度。即使在对患者及其他团队特征进行调整后，那些对多种专科医生就诊需要预先授权的团队中的患者，其满意度仍显著低于（p≤0.001）预先授权要求较少的团队中的患者。在前一年想看专科医生但未看成的患者，其满意度显著低于那些想看专科医生且实际看成的患者（p<0.001）。此外，想看专科医生但未看成的患者比看成专科医生的患者更有可能想要退出健康计划（40%对18%，p≤0.001），也更有可能不向朋友推荐自己所在的团队（38%对13%，p≤0.001）。
限制直接看专科医生的政策，尤其是拒绝患者希望的转诊，与患者满意度显著降低、退出意愿增加以及向朋友推荐该团队的可能性降低有关。健康计划和医生团队在设计减少专科护理使用的策略时需要考虑这些因素。
