Lieu Tracy A, Finkelstein Jonathan A, Lozano Paula, Capra Angela M, Chi Felicia W, Jensvold Nancy, Quesenberry Charles P, Farber Harold J
Center for Child Health Care Studies, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts 02215, USA.
Pediatrics. 2004 Jul;114(1):e102-10. doi: 10.1542/peds.114.1.e102.
More than half of Medicaid enrollees are now in managed care. Scant information exists about which policies of practice sites improve quality of care in managed Medicaid. Children with asthma are a sentinel group for Medicaid quality monitoring because they are at elevated risk for adverse outcomes. The objective of this study was to identify practice-site policies and features associated with quality of care for Medicaid-insured children with asthma.
A prospective cohort study with 1-year follow-up was conducted in 5 health plans in California, Washington, and Massachusetts. Data were collected via telephone interviews with parents at baseline and 1 year, surveys of practice sites and clinicians, and computerized databases. The practice site survey asked about policies to promote cultural competence, the use of several types of reports to clinicians, support for self-management of asthma, case management and care coordination, and access to and continuity of care. Quality of care was evaluated on the basis of 5 measures: 1) preventive medication underuse based on parent report; 2) the parent's rating of asthma care; 3) the 1-year change in the child's asthma physical status based on a standardized measure; 4) preventive medication underprescribing based on computerized data; and 5) the occurrence of a hospital-based episode.
Of the 1663 children in the study population, 67% had persistent asthma at baseline based on parent report of symptoms and medications. At 1-year follow-up, 65% of the children with persistent asthma were underusing preventive medication based on parent report. In multivariate analyses, patients of practice sites with the highest cultural competence scores were less likely to be underusing preventive asthma medications based on parent report at follow-up (odds ratio [OR]: 0.15; 95% confidence interval [CI]: 0.06-0.41 for the highest vs lowest categories) and had better parent ratings of care. The use of asthma reports to clinicians was predictive of less preventive medication underprescribing based on computerized data (OR: 0.33; 95% CI: 0.16-0.69), better parent ratings of care, and better asthma physical status at follow-up. Patients of practice sites with policies to promote access and continuity had less underuse of preventive medications (OR: 0.56; 95% CI: 0.34-0.93). Among the 83 practice sites, the practice site's size, organizational type, percentage of patients insured by Medicaid, mechanism of payment for specialty care, and other primary care features were not consistently associated with quality measures.
Practice-site policies to promote cultural competence, the use of reports to clinicians, and access and continuity predicted higher quality of care for children with asthma in managed Medicaid.
如今，超过半数的医疗补助计划参保者都加入了管理式医疗。关于哪些医疗机构政策能提高管理式医疗补助计划的医疗质量，相关信息极为匮乏。哮喘患儿是医疗补助计划质量监测的一个哨点群体，因为他们出现不良后果的风险较高。本研究的目的是确定与医疗补助计划参保的哮喘患儿医疗质量相关的医疗机构政策和特征。
在加利福尼亚州、华盛顿州和马萨诸塞州的5个健康计划中开展了一项为期1年随访的前瞻性队列研究。通过在基线期和1年后与家长进行电话访谈、对医疗机构和临床医生进行调查以及利用计算机化数据库来收集数据。医疗机构调查问卷询问了促进文化能力的政策、向临床医生提供的几种报告的使用情况、对哮喘自我管理的支持、病例管理和护理协调以及医疗服务的可及性和连续性。基于以下5项指标对医疗质量进行评估：1）根据家长报告得出的预防性药物使用不足情况；2）家长对哮喘护理的评分；3）基于标准化测量得出的患儿哮喘身体状况的1年变化；4）根据计算机化数据得出的预防性药物处方不足情况；5）医院就诊事件的发生情况。
在研究人群的1663名儿童中，根据家长对症状和用药情况的报告，67%的儿童在基线期患有持续性哮喘。在1年随访时，根据家长报告，65%的持续性哮喘患儿预防性药物使用不足。在多变量分析中，文化能力得分最高的医疗机构的患者在随访时根据家长报告预防性哮喘药物使用不足的可能性较小（最高类别与最低类别相比，优势比[OR]：0.15；95%置信区间[CI]：0.06 - 0.41），且家长对护理的评分更高。向临床医生提供哮喘报告可预测基于计算机化数据的预防性药物处方不足情况较少（OR：0.33；95% CI：0.16 - 0.69）、家长对护理的评分更高以及随访时哮喘身体状况更好。有促进医疗服务可及性和连续性政策的医疗机构的患者预防性药物使用不足的情况较少（OR：0.56；95% CI：0.34 - 0.93）。在83个医疗机构中，医疗机构的规模、组织类型、医疗补助计划参保患者的比例、专科护理的支付机制以及其他初级保健特征与质量指标之间并无一致的关联。
促进文化能力、向临床医生提供报告以及医疗服务可及性和连续性的医疗机构政策预示着管理式医疗补助计划中哮喘患儿的医疗质量更高。
