Naessens James M, Baird Macaran A, Van Houten Holly K, Vanness David J, Campbell Claudia R
Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
Ann Fam Med. 2005 Jul-Aug;3(4):324-30. doi: 10.1370/afm.352.
We wanted to identify risk factors for persistently high use of primary care.
We analyzed outpatient office visits to practitioners in family medicine, general internal medicine, general pediatrics, and obstetrics for 1997-1999 among patients in a small Midwestern city covered by a fee-for-service insurance plan with no co-payments for physician visits and no requirement for referral to specialty care. Logistic regression was used to predict which patients with 10 or more primary care visits in 1997 would repeat high use in 1998 based on demographic and diagnostic categories (adjusted clinical groups [ACGs]). A confirmatory data set (high primary care use in 1998 persistent into 1999) was used to evaluate the model.
Two percent of the 54,074 patients had 10 or more primary care visits in 1997, and of these, almost 19% had 10 or more visits in the next year. Among adults, 4 ambulatory diagnosis groups (ADGs) were simultaneously positive predictors of repeated high primary care visits: unstable chronic medical conditions, see and reassure conditions, minor time-limited psychosocial conditions, and minor signs and symptoms. Meanwhile, pregnancy was negatively associated. The area under the receiver operating characteristic (ROC) curve was 0.794 for adults in the developmental data set and 0.752 in the confirmatory data set, indicating a moderately accurate assessment. A satisfactory model was not developed for pediatric patients.
Many persistently high primary care users appear to be overserviced but underserved, with underlying problems not addressed by a medical approach. Some may benefit from psychosocial support, whereas others may be good candidates for disease management interventions.
我们想要确定初级保健持续高使用量的风险因素。
我们分析了1997 - 1999年期间，在中西部一个小城市中，参加了按服务收费保险计划的患者，该计划对医生诊疗不设自付费用，也无需转诊至专科护理。这些患者到家庭医学、普通内科、普通儿科和妇产科医生处进行门诊就诊。采用逻辑回归分析，根据人口统计学和诊断类别（调整后的临床分组[ACG]），预测1997年进行了10次或更多次初级保健就诊的患者在1998年是否会再次出现高就诊量。使用一个验证数据集（1998年初级保健高使用量持续到1999年）来评估该模型。
在54,074名患者中，2%在1997年进行了10次或更多次初级保健就诊，其中近19%在次年进行了10次或更多次就诊。在成年人中，4个门诊诊断组（ADG）同时是初级保健高就诊量反复出现的阳性预测因素：不稳定的慢性疾病状况、观察并安抚状况、轻度限时心理社会状况以及轻微体征和症状。同时，怀孕与之呈负相关。在开发数据集中，成年人的受试者工作特征（ROC）曲线下面积为0.794，在验证数据集中为0.752，表明评估具有中等准确性。未为儿科患者开发出令人满意的模型。
许多初级保健持续高使用量的患者似乎接受了过度服务但未得到充分服务，潜在问题未通过医学方法解决。一些患者可能受益于心理社会支持，而另一些患者可能是疾病管理干预的合适对象。
