Wee C C, Phillips R S, Burstin H R, Cook E F, Puopolo A L, Brennan T A, Haas J S
Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
Am J Med. 2001 Feb 15;110(3):181-7. doi: 10.1016/s0002-9343(00)00692-6.
We examined whether physician factors, particularly financial productivity incentives, affect the provision of preventive care.
We surveyed and reviewed the charts of 4,473 patients who saw 1 of 169 internists from 11 academically affiliated primary care practices in Boston. We abstracted cancer risk factors, comorbid conditions, and the dates of the last Papanicolaou (Pap) smear, mammogram, cholesterol screening, and influenza vaccination. We obtained physician information including the method of financial compensation through a mailed physician survey. We used multivariable logistic regression to examine the association between physician factors and four outcomes based on Health Plan Employer Data and Information Set (HEDIS) measures: (1) Pap smear within the prior 3 years among women 20 to 75 years old; (2) mammogram in the prior 2 years among women 52 to 69 years old; (3) cholesterol screening within the prior 5 years among patients 40 to 64 years old; and (4) influenza vaccination among patients 65 years old and older. All analyses accounted for clus-tering by provider and site and were converted into adjusted rates.
After adjustment for practice site, clinical, and physician factors, patients cared for by physicians with financial productivity incentives were significantly less likely than those cared for by physicians without this incentive to receive Pap smears (rate difference, 12%; 95% confidence interval [CI]: 5% to 18%) and cholesterol screening (rate difference, 4%; 95% CI: 0% to 8%). Financial incentives were not significantly associated with rates of mammography (rate difference, -3%; 95% CI: -15% to 10%) or influenza vaccination (rate difference, -13%; 95% CI: -28% to 2%).
Our findings suggest that some financial productivity incentives may discourage the performance of certain forms of preventive care, specifically Pap smears and cholesterol screening. More studies are needed to examine the effects of financial incentives on the quality of care, and to examine whether quality improvement interventions or incentives based on quality improve the performance of preventive care.
我们研究了医生因素，尤其是经济生产效率激励措施，是否会影响预防性医疗服务的提供。
我们对4473名患者进行了调查并查阅了他们的病历，这些患者就诊于波士顿11家学术附属初级保健机构中的169名内科医生。我们提取了癌症风险因素、合并症以及上次巴氏涂片检查、乳房X光检查、胆固醇筛查和流感疫苗接种的日期。我们通过邮寄医生调查问卷获取了医生信息，包括经济补偿方式。我们使用多变量逻辑回归分析，基于健康计划雇主数据与信息集（HEDIS）指标，研究医生因素与四个结果之间的关联：（1）20至75岁女性在过去3年内进行巴氏涂片检查；（2）52至69岁女性在过去2年内进行乳房X光检查；（3）40至64岁患者在过去5年内进行胆固醇筛查；（4）65岁及以上患者接种流感疫苗。所有分析均考虑了提供者和地点的聚类情况，并转换为调整率。
在对医疗机构地点、临床和医生因素进行调整后，与没有经济生产效率激励措施的医生所照顾的患者相比，受到有此类激励措施医生照顾的患者接受巴氏涂片检查（率差为12%；95%置信区间[CI]：5%至18%）和胆固醇筛查（率差为4%；95%CI：0%至8%）的可能性显著降低。经济激励措施与乳房X光检查率（率差为-3%；95%CI：-15%至10%）或流感疫苗接种率（率差为-13%；95%CI：-28%至）无显著关联。
我们的研究结果表明，一些经济生产效率激励措施可能会阻碍某些形式的预防性医疗服务的开展，特别是巴氏涂片检查和胆固醇筛查。需要更多研究来考察经济激励措施对医疗质量的影响，以及基于质量改进的干预措施或激励措施是否能提高预防性医疗服务的绩效。
