Grembowski David E, Martin Diane, Diehr Paula, Patrick Donald L, Williams Barbara, Novak Louise, Deyo Richard, Katon Wayne, Dickstein Deborah, Engelberg Ruth, Goldberg Harold
Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle 98195-7660, USA.
Health Serv Res. 2003 Feb;38(1 Pt 1):1-19. doi: 10.1111/1475-6773.00102.
To determine whether managed care controls were associated with reduced access to specialists and worse outcomes among primary care patients with pain.
DATA SOURCES/STUDY SETTING: Patient, physician, and office manager questionnaires collected in the Seattle area in 1996-1997, plus data abstracted from patient records and health plans.
A prospective cohort study of 2,275 adult patients with common pain problems recruited in the offices of 261 primary care physicians in Seattle.
Patients completed a waiting room questionnaire and follow-up surveys at the end of the first and sixth months to measure access to specialists and outcomes. Intensity of managed care controls measured by plan managed care index and benefit/cost-sharing indexes, office managed care index, physician compensation, financial incentives, and use of clinical guidelines.
A financial withhold for referral was associated with a lower likelihood of referral to a physician specialist, a greater likelihood of seeing a specialist without referral, and a lower patient rating of care from the primary physician. Otherwise, patients in more managed offices and with greater out-of-network plan benefits had greater access to specialists. Patients with more versus less managed care had similar health outcomes, but patients in more managed offices had lower ratings of care provided by their primary physicians.
Increased managed care controls were generally not associated with reduced access to specialists and worse health outcomes for primary care patients with pain, but patients in more managed offices had lower ratings of care provided by their primary physicians.
确定管理式医疗控制措施是否与初级护理疼痛患者看专科医生的机会减少及预后较差有关。
数据来源/研究背景：1996 - 1997年在西雅图地区收集的患者、医生和办公室经理调查问卷，以及从患者记录和健康计划中提取的数据。
对西雅图261名初级护理医生办公室招募的2275名患有常见疼痛问题的成年患者进行前瞻性队列研究。
患者在候诊室完成一份调查问卷，并在第一个月和第六个月末进行随访调查，以衡量看专科医生的机会和预后。管理式医疗控制强度通过计划管理式医疗指数、福利/成本分摊指数、办公室管理式医疗指数、医生薪酬、经济激励措施以及临床指南的使用来衡量。
转诊的经济扣留与转诊至专科医生的可能性降低、未经转诊看专科医生的可能性增加以及患者对初级医生护理的评分降低有关。否则，在管理更严格的办公室且有更多网络外计划福利的患者看专科医生的机会更大。接受更多与更少管理式医疗的患者健康预后相似，但在管理更严格办公室的患者对其初级医生提供的护理评分较低。
管理式医疗控制措施增加一般与初级护理疼痛患者看专科医生的机会减少及健康预后较差无关，但在管理更严格办公室的患者对其初级医生提供的护理评分较低。
