医疗补助管理式医疗对医疗服务利用的影响：婴儿急诊科和门诊服务

Effects of Medicaid managed care on health care use: infant emergency department and ambulatory services.

作者信息

Alessandrini E A, Shaw K N, Bilker W B, Perry K A, Baker M D, Schwarz D F

机构信息

Division of Emergency Medicine, The Children's Hospital of Philadelphia, USA.

出版信息

Pediatrics. 2001 Jul;108(1):103-10. doi: 10.1542/peds.108.1.103.

DOI:10.1542/peds.108.1.103

PMID:11433061

Abstract

OBJECTIVE

Many urban children rely on emergency departments (ED) for ambulatory care. The objective of this study was to determine whether enrollment in Medicaid managed care (MMC) alters ED or other ambulatory care compared with fee-for-service Medicaid (FFSM).

METHODS

A prospective cohort study of infants born between May 1994 and April 1995 with a 6-month follow-up period was conducted in an urban, teaching hospital and surrounding ambulatory settings. A consecutive sample of 644 infants enrolled in MMC or FFSM was studied; 92% of eligible patients were enrolled, and 94% completed follow-up. The main outcome measures were 1) proportion of patients in each group visiting an ED, primary care practitioner (PCP), or specialist; 2) mean number of visits per group; and 3) ED reliance (EDR) defined as the proportion of all ambulatory visits occurring in an ED.

RESULTS

Fifty-six percent of MMC and 54% of FFSM patients visited an ED (relative risk: 1.03; 95% confidence interval [CI]: 0.83, 1.27). More MMC patients had a sick visit to their PCP (relative risk: 1.34; 95% CI: 1.03, 1.74); no difference in proportion with well-child or specialty visits was found. Although the mean number of total ambulatory, ED, and specialty visits was the same, MMC patients had fewer well-child and more sick visits to the PCP than FFSM patients (P =.01). EDR was 21% for both groups (P =.95). After adjustment for other factors in multivariate analysis, insurance status remained unassociated with EDR (adjusted odds ratio [OR]: 0.91; 95% CI: 0.56, 1.69). Factors associated with EDR included United States-born mother (OR: 5.34; 95% CI: 1.61, 17.68) and use of a hospital-based primary care physician (OR: 2.00; 95% CI: 1.34, 2.98). Variables that characterized infants who were less likely to be ED reliant included adequate maternal prenatal care (OR: 0.52; 95% CI: 0.34, 0.78) and having a mother who completed high school (OR: 0.67; 95% CI: 0.45, 0.99).

CONCLUSIONS

Enrollment in MMC did not alter ED usage patterns when compared with FFSM. Some variation in use of other ambulatory services was detected.

摘要

目的

许多城市儿童依靠急诊科提供门诊护理。本研究的目的是确定与按服务收费的医疗补助计划（FFSM）相比，加入医疗补助管理式医疗（MMC）是否会改变急诊科或其他门诊护理的使用情况。

方法

在一家城市教学医院及周边门诊机构对1994年5月至1995年4月出生的婴儿进行了一项前瞻性队列研究，随访期为6个月。对连续抽取的644名加入MMC或FFSM的婴儿进行了研究；92%符合条件的患者入组，94%完成了随访。主要结局指标为：1）每组中就诊于急诊科（ED）、初级保健医生（PCP）或专科医生的患者比例；2）每组的平均就诊次数；3）急诊依赖率（EDR），定义为在急诊科进行的所有门诊就诊的比例。

结果

56%的MMC患者和54%的FFSM患者就诊于急诊科（相对危险度：1.03；95%置信区间[CI]：0.83，1.27）。更多的MMC患者因患病就诊于其初级保健医生（相对危险度：1.34；95%CI：1.03，1.74）；在进行健康儿童或专科就诊的患者比例方面未发现差异。尽管总的门诊、急诊科和专科就诊的平均次数相同，但MMC患者进行健康儿童就诊的次数比FFSM患者少，而因患病就诊于初级保健医生的次数比FFSM患者多（P = 0.01）。两组的急诊依赖率均为21%（P = 0.95）。在多变量分析中对其他因素进行调整后，保险状态与急诊依赖率仍无关联（调整后的优势比[OR]：0.91；95%CI：0.56，1.69）。与急诊依赖率相关的因素包括在美国出生的母亲（OR：5.34；95%CI：1.61，17.68）以及使用医院的初级保健医生（OR：2.00；95%CI：1.34，2.98）。那些不太可能依赖急诊科的婴儿的特征变量包括母亲有充分的产前护理（OR：0.52；95%CI：0.34，0.78）以及母亲完成了高中学业（OR：0.67；95%CI：0.45，0.99）。