Rask K J, Deaton C, Culler S D, Kohler S A, Morris D C, Alexander W A, Pope R G, Weintraub W S
Emory University Center for Clinical Evaluation Sciences, Rollins School of Public Health, Atlanta, GA 30322, USA.
Am J Manag Care. 1999 Oct;5(10):1274-82.
To determine whether patients with chest pain referred to a cardiologist from a gatekeeper managed care organization differ from those referred from an open-access managed care organization.
Retrospective study using clinical and claims data from a cardiac network database.
We reviewed data from 1414 patients with chest pain or angina who were referred to a cardiologist between January 1, 1995, and June 30, 1996. We examined baseline clinical characteristics and subsequent physician practice patterns for these patients, who were referred from either a primary care gatekeeper model (n = 490) or an open-access model (n = 924).
Although twice as many open-access patients were referred to a cardiologist, there were no differences in patient demographics or clinical characteristics at the time of referral. Cardiologists ordered similar diagnostic tests for patients from both types of managed care plans, and gatekeeper patients did not have a higher rate of abnormal tests. Rates of cardiac catheterization, coronary angioplasty, myocardial infarction, and hospitalization were similar in both groups. A significantly higher percentage of gatekeeper patients received a cardiac catheterization on the day of referral (7% versus 1%; P = .05). Open-access patients were significantly more likely to continue to be seen by a cardiologist (44% versus 28%; P < .01). Cardiology professional charges per patient were lower among gatekeeper patients ($972 +/- 1398 versus $1187 +/- 1897; P = .06), and total cardiology professional charges were significantly lower for the gatekeeper group because of the smaller number of patients seen.
The type of cardiology services provided to patients with chest pain was not affected by the primary care administrative structure of the managed care organization, but the higher volume of patient referrals from the open-access plan may be an important consideration for cardiology practices participating in capitated contracts. The lower volume of referrals and coordination of care suggest potential cost advantages for the gatekeeper model.
确定从守门人管理式医疗组织转诊至心脏病专家处的胸痛患者与从开放式接入管理式医疗组织转诊的患者是否存在差异。
利用心脏网络数据库中的临床和理赔数据进行回顾性研究。
我们回顾了1995年1月1日至1996年6月30日期间转诊至心脏病专家处的1414例胸痛或心绞痛患者的数据。我们检查了这些患者的基线临床特征以及后续医生的诊疗模式，这些患者分别来自初级保健守门人模式（n = 490）或开放式接入模式（n = 924）。
尽管转诊至心脏病专家处的开放式接入患者数量是守门人模式患者的两倍，但转诊时患者的人口统计学特征或临床特征并无差异。心脏病专家为来自两种管理式医疗计划的患者开具了相似的诊断检查，且守门人模式患者的检查异常率并不更高。两组的心脏导管插入术、冠状动脉血管成形术、心肌梗死和住院率相似。守门人模式患者在转诊当天接受心脏导管插入术 的比例显著更高（7% 对1%；P = .05）。开放式接入患者继续由心脏病专家诊治的可能性显著更高（44% 对28%；P < .01）。守门人模式患者的人均心脏病专业费用较低（972美元 ± 1398美元对1187美元 ± 1897美元；P = .06），且由于就诊患者数量较少，守门人模式组的心脏病专业总费用显著更低。
为胸痛患者提供的心脏病学服务类型不受管理式医疗组织初级保健管理结构的影响，但来自开放式接入计划的患者转诊量较大可能是参与按人头付费合同的心脏病学实践的一个重要考虑因素。转诊量较低和医疗协调表明守门人模式具有潜在的成本优势。
