Shortell S M, Zazzali J L, Burns L R, Alexander J A, Gillies R R, Budetti P P, Waters T M, Zuckerman H S
School of Public Health, University of California, Berkeley, 94720-7360, USA.
Med Care. 2001 Jul;39(7 Suppl 1):I62-78.
To assess the extent to which market pressures, compensation incentives, and physician medical group culture are associated with the use of evidence-based medicine practices in physician organizations.
Cross-sectional exploratory study of 56 medical groups affiliated with 15 integrated health systems from across the United States, involving 1,797 physician respondents. Larger medical groups and multispecialty groups were overrepresented compared with the United States as a whole. Data are from two sources: (1) surveys of physicians assessing the culture of the medical groups in which they work, and (2) surveys of medical directors and other managerial key informants pertaining to care management practices, compensation methods, and the management and governance of the medical groups. Physician-level data were aggregated to the group level to attain measures of group culture and then merged with the data regarding care management, incentives, and management and governance. Stepwise multiple regression was used to examine the study hypotheses.
As hypothesized, the number of different types of compensation incentives used (cost containment, productivity, quality) was positively associated with the comprehensiveness of care management practices. The degree of salary control (ie, market-based salary grades and ranges versus the use of bookings or fees and individual negotiation) was also positively associated with the deployment of care management practices. As hypothesized, market pressures in the form of percentages of health maintenance and preferred provider organization patients seen were generally positively associated with the use of care management practices. Organizational culture had no association except that a patient-centered culture in combination with a greater number of different types of compensation incentives used was positively associated with greater use of care management practices.
Both compensation incentives and managed care market pressures were significantly associated with the use of evidence-based care management practices. The lack of association for culture may be due to the relatively amorphous nature of most physician organizations at this point.
评估市场压力、薪酬激励措施以及医师医疗集团文化与医师组织中循证医学实践应用之间的关联程度。
对来自美国各地15个综合医疗系统下属的56个医疗集团进行横断面探索性研究，涉及1797名医师受访者。与美国整体情况相比，规模较大的医疗集团和多专科医疗集团占比过高。数据来自两个来源：（1）对医师进行的调查，评估他们所在医疗集团的文化；（2）对医疗主任和其他管理关键信息提供者进行的调查，涉及护理管理实践、薪酬方法以及医疗集团的管理与治理。医师层面的数据汇总到集团层面以获得集团文化的衡量指标，然后与有关护理管理、激励措施以及管理与治理的数据合并。采用逐步多元回归来检验研究假设。
正如所假设的，所使用的不同类型薪酬激励措施（成本控制、生产率、质量）的数量与护理管理实践的全面性呈正相关。薪资控制程度（即基于市场的薪资等级和范围与使用预约量或费用以及个人谈判相比）也与护理管理实践的部署呈正相关。正如所假设的，以健康维护组织和首选提供者组织患者所占百分比形式存在的市场压力通常与护理管理实践的应用呈正相关。组织文化没有关联，只是以患者为中心的文化与所使用的不同类型薪酬激励措施数量较多相结合时，与更多地使用护理管理实践呈正相关。
薪酬激励措施和管理式医疗市场压力均与循证护理管理实践的应用显著相关。文化缺乏关联可能是由于此时大多数医师组织的性质相对模糊。
