Katz J N, Solomon D H, Schaffer J L, Horsky J, Burdick E, Bates D W
Division of Rheumatology, Immunology and Allergy, Robert Brigham Multipurpose Arthritis and Musculoskeletal Diseases Center, Boston, Massachusetts, USA.
Am J Med. 2000 Jan;108(1):28-35. doi: 10.1016/s0002-9343(99)00313-7.
Previous studies have suggested that specialists may achieve better clinical outcomes for patients, albeit often at greater cost. We sought to compare outcomes of care and resource utilization among patients with shoulder or knee problems who were treated by general internists, rheumatologists, and orthopedic surgeons.
Outpatients with knee or shoulder complaints who were seen by general internists, rheumatologists, or orthopedic surgeons at an academic medical center were administered questionnaires at enrollment in the study and again 3 months later. The questionnaires included validated measures of satisfaction, functional status, and pain severity, as well as resource utilization. We compared baseline clinical characteristics, satisfaction with care, resource utilization, and changes in function and symptoms during 3 months of follow-up among patients who were cared for by the three different types of providers.
A total of 534 patients responded to the baseline survey and 436 (82%) to the 3-month follow-up survey. About 60% (n = 323) had knee pain. Orthopedists cared for 40% (n = 211) of the patients, with the remainder treated in approximately equal numbers by general internists or rheumatologists. At baseline, patients of internists had less severe pain (differences of 0.3 to 0.6 points on a 1 to 5 scale, P <0.05) and functional limitations (differences of 0.4 to 0.6 points on a 1 to 5 scale, P <0.0006) than patients of rheumatologists and orthopedic surgeons. Adjusting for baseline differences, there were no significant differences among provider groups in pain relief or functional improvement during follow-up. However, in adjusted analyses, patients with shoulder pain who were cared for by orthopedic surgeons were least satisfied with the office environment [adjusted mean (+/- SD) satisfaction score of 1.6 +/- 0.8 on a 1 to 4 scale for orthopedic surgeons vs 1.3 +/- 0.8 for rheumatologists and 1.4 +/- 0.8 for internists, P = 0.004]. Among patients with knee pain, those treated by rheumatologists and orthopedic surgeons were more satisfied with the doctor-patient interaction (adjusted mean satisfaction scores of 1.1 +/- 0.9 for rheumatologists and 1.2 +/- 0.7 for orthopedic surgeons on a 1 to 4 scale vs 1.4 +/- 0.8 for general internists, P = 0.003). Orthopedic surgeons obtained significantly more radiographs of the knee or shoulder and more magnetic resonance imaging scans of the knee. Rheumatologists performed significantly more aspirations or injection procedures. Among all patients, those treated by rheumatologists were most satisfied with the physician interaction, and those treated by orthopedic surgeons were most satisfied with treatment results.
The relative benefits of specialist compared with generalist care for patients with knee or shoulder pain depend on the importance attached to resource utilization, patient satisfaction, and health outcomes.
以往研究表明，专科医生可能为患者带来更好的临床结局，尽管成本往往更高。我们试图比较由普通内科医生、风湿病学家和骨科医生治疗的肩部或膝部问题患者的护理结局和资源利用情况。
在一所学术医疗中心就诊于普通内科医生、风湿病学家或骨科医生的膝部或肩部不适的门诊患者，在研究入组时以及3个月后再次接受问卷调查。问卷包括经过验证的满意度、功能状态、疼痛严重程度以及资源利用的测量指标。我们比较了由三种不同类型医疗服务提供者护理的患者在3个月随访期间的基线临床特征、护理满意度、资源利用情况以及功能和症状变化。
共有534例患者回复了基线调查，436例（82%）回复了3个月随访调查。约60%（n = 323）有膝痛。骨科医生护理了40%（n = 211）的患者，其余患者由普通内科医生或风湿病学家大致等量治疗。在基线时，内科医生的患者疼痛程度较轻（在1至5分的量表上相差0.3至0.6分，P <0.05），功能受限程度也较轻（在1至5分的量表上相差0.4至0.6分，P <0.0006），低于风湿病学家和骨科医生的患者。在对基线差异进行调整后，各医疗服务提供者组在随访期间的疼痛缓解或功能改善方面没有显著差异。然而，在调整分析中，由骨科医生护理的肩部疼痛患者对诊室环境最不满意[骨科医生在1至4分的量表上调整后的平均（±标准差）满意度评分为1.6±0.8，而风湿病学家为1.3±0.8，内科医生为1.4±0.8，P = 0.004]。在膝痛患者中，由风湿病学家和骨科医生治疗的患者对医患互动更满意（在1至4分的量表上，风湿病学家的调整后平均满意度评分为1.1±0.9，骨科医生为1.2±0.7，而普通内科医生为1.4±0.8，P = 0.003）。骨科医生对膝部或肩部进行X线检查以及对膝部进行磁共振成像扫描的次数显著更多。风湿病学家进行的抽吸或注射操作显著更多。在所有患者中，由风湿病学家治疗的患者对医生互动最满意，由骨科医生治疗的患者对治疗结果最满意。
对于膝部或肩部疼痛患者，专科医生护理与全科医生护理相比的相对益处取决于对资源利用、患者满意度和健康结局的重视程度。
