Giuffrida A, Gosden T, Forland F, Kristiansen I S, Sergison M, Leese B, Pedersen L, Sutton M
Sustainable Development Department, Social Development Division, Inter-American Development Bank, 1300 New York Avenue, NW, Stop W0502, Washington DC 20577, USA.
Cochrane Database Syst Rev. 2000;1999(3):CD000531. doi: 10.1002/14651858.CD000531.
The method by which physicians are paid may affect their professional practice. Although payment systems may be used to achieve policy objectives (e.g. improving quality of care, cost containment and recruitment to under-served areas), little is known about the effects of different payment systems in achieving these objectives. Target payments are a payment system which remunerate professionals only if they provide a minimum level of care.
To evaluate the impact of target payments on the professional practice of primary care physicians (PCPs) and health care outcomes.
We searched the Cochrane Effective Practice and Organisation of Care Group specialised register; the Cochrane Controlled Trials Register; MEDLINE (1966 to October 1997); BIDS EMBASE (1980 to October 1997); BIDS ISI (1981 to October 1997); EconLit (1969 to October 1997); HealthStar (1975 to October 1997) Helmis (1984 to October 1997); health economics discussion paper series of the Universities of York, Aberdeen, Sheffield, Bristol, Brunel, and McMaster; Swedish Institute of Health Economics; RAND corporation; and reference lists of articles.
Randomised trials, controlled before and after studies and interrupted time series analyses of interventions comparing the impact of target payments to primary care professionals with alternative methods of payment, on patient outcomes, health services utilisation, health care costs, equity of care, and PCP satisfaction with working environment.
Two reviewers independently extracted data and assessed study quality.
Two studies were included involving 149 practices. The use of target payments in the remuneration of PCPs was associated with improvements in immunisation rates, but the increase was statistically significant in only one of the two studies.
REVIEWER'S CONCLUSIONS: The evidence from the studies identified in this review is not of sufficient quality or power to obtain a clear answer to the question as to whether target payment remuneration provides a method of improving primary health care. Additional efforts should be directed in evaluating changes in physicians' remuneration systems. Although it would not be difficult to design a randomised controlled trial to evaluate the impact of such payment systems, it would be difficult politically to conduct such trials.
医生的薪酬支付方式可能会影响其专业实践。尽管薪酬支付系统可用于实现政策目标（如提高医疗质量、控制成本以及吸引医生到服务不足地区工作），但对于不同支付系统在实现这些目标方面的效果却知之甚少。目标支付是一种仅在专业人员提供最低水平医疗服务时才给予报酬的支付系统。
评估目标支付对初级保健医生（PCP）的专业实践及医疗保健结果的影响。
我们检索了Cochrane有效实践与医疗组织小组专业注册库；Cochrane对照试验注册库；MEDLINE（1966年至1997年10月）；BIDS EMBASE（1980年至1997年10月）；BIDS ISI（1981年至1997年10月）；EconLit（1969年至1997年10月）；HealthStar（1975年至1997年10月）；Helmis（1984年至1997年10月）；约克大学、阿伯丁大学、谢菲尔德大学、布里斯托大学、布鲁内尔大学和麦克马斯特大学的卫生经济学讨论文件系列；瑞典卫生经济研究所；兰德公司；以及文章的参考文献列表。
随机试验、前后对照研究以及对干预措施的中断时间序列分析，比较目标支付与其他支付方式对初级保健专业人员的影响，包括对患者结局、卫生服务利用、医疗保健成本、医疗公平性以及初级保健医生对工作环境的满意度。
两名评价员独立提取数据并评估研究质量。
纳入两项研究，涉及149个医疗机构。在初级保健医生薪酬中使用目标支付与免疫接种率的提高相关，但在两项研究中只有一项的提高具有统计学意义。
本评价中所识别研究的证据质量或效力不足以明确回答目标支付薪酬是否提供了一种改善初级卫生保健的方法这一问题。应加大力度评估医生薪酬系统的变化。尽管设计一项随机对照试验来评估此类支付系统的影响并非难事，但在政治上开展此类试验会很困难。
