Hillman A L, Ripley K, Goldfarb N, Weiner J, Nuamah I, Lusk E
Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pennsylvania, Philadelphia 19104-6021, USA.
Pediatrics. 1999 Oct;104(4 Pt 1):931-5. doi: 10.1542/peds.104.4.931.
Immunizations and other cost-effective preventive services remain underused by many children, especially those living in poverty. Given the effectiveness of provider-based tracking systems and the widespread use by managed care organizations of financial incentives to influence physician practice patterns, we designed and tested an intervention combining these strategies. We studied whether a system of semiannual assessment and feedback, coupled with financial incentives, could improve pediatric preventive care in a Medicaid health maintenance organization (HMO).
We randomly assigned primary care sites serving children in a Medicaid HMO to one of three groups: a feedback group (where physicians received written feedback about compliance scores), a feedback and incentive group (where physicians received feedback and a financial bonus when compliance criteria were met), and a control group. We evaluated compliance with pediatric preventive care guidelines through semiannual chart audits during the years 1993 to 1995.
Compliance with pediatric preventive care improved dramatically in the study period. Repeated measures ANOVA demonstrated a significant increase in all three study groups throughout the time in total compliance scores (from 56%-73%), as well as scores for immunizations (from 62%-79%) and other preventive care (from 54%-71%). However, no significant differences were observed between either intervention group and the control group, nor were there any interaction (group-by-time) effects.
Feedback to physicians, with or without financial incentives, did not improve pediatric preventive care in this Medicaid HMO during a time of rapid, secular improvements in care. Possible explanations include the context and timing of the intervention, the magnitude of the financial incentives, and lack of physician awareness of the intervention.
许多儿童，尤其是贫困儿童，对免疫接种及其他具有成本效益的预防服务的利用率仍然较低。鉴于基于医疗机构的追踪系统的有效性以及管理式医疗组织广泛使用经济激励措施来影响医生的执业模式，我们设计并测试了一种结合这些策略的干预措施。我们研究了一个每半年进行一次评估和反馈并辅以经济激励的系统能否改善医疗补助健康维护组织（HMO）中的儿童预防性保健服务。
我们将为医疗补助HMO中的儿童提供初级保健服务的地点随机分为三组：反馈组（医生收到关于依从性评分的书面反馈）、反馈与激励组（医生收到反馈且在达到依从性标准时获得经济奖励）和对照组。我们在1993年至1995年期间通过每半年一次的病历审核来评估对儿童预防性保健指南的依从情况。
在研究期间，对儿童预防性保健的依从性显著提高。重复测量方差分析表明，在整个研究期间，所有三个研究组在总体依从性评分（从56% - 73%）、免疫接种评分（从62% - 79%）和其他预防性保健评分（从54% - 71%）方面均有显著提高。然而，在两个干预组与对照组之间未观察到显著差异，也不存在任何交互作用（组×时间）效应。
在医疗服务快速、长期改善的时期，无论有无经济激励，向医生提供反馈均未改善该医疗补助HMO中的儿童预防性保健服务。可能的解释包括干预的背景和时机、经济激励的幅度以及医生对干预措施缺乏认知。
