Sirovich Brenda E, Gottlieb Daniel J, Welch H Gilbert, Fisher Elliott S
Veterans Affairs Medical Center Outcomes Group, White River Junction, Vermont 05009, USA.
Ann Intern Med. 2006 May 2;144(9):641-9. doi: 10.7326/0003-4819-144-9-200605020-00007.
Research has documented dramatic differences in health care utilization and spending across U.S. regions with similar levels of patient illness. Although patient outcomes and quality of care have been found to be no better in regions of high health care intensity, it is unknown whether physicians in these regions feel more capable of providing good patient care than those in low-intensity regions.
To determine whether physicians in high-intensity regions feel better able to care for patients than physicians in low-intensity regions.
Physician telephone survey.
51 metropolitan and 9 nonmetropolitan areas of the United States and a supplemental national sample.
10,577 physicians who provided care to adults in 1998 or 1999 were surveyed for the Community Tracking Study (response rate, 61%).
The End-of-Life Expenditure Index, a measure of spending that reflects differences in the overall quantity of medical services provided rather than differences in illness or price, was used to determine health care intensity in the physicians' community. Outcomes included physicians' perceived availability of clinical services, ability to provide high-quality care to patients, and career satisfaction.
Although the highest-intensity regions have substantially more hospital beds and specialists per capita, physicians in these regions reported more difficulty obtaining needed services for their patients. The proportion of physicians who felt able to obtain elective hospital admissions ranged from 50% in high-intensity regions to 64% in the lowest-intensity region (P < 0.001 for the relationship between intensity and perceived ability to obtain hospital admissions); the proportion of physicians who felt able to obtain high-quality specialist referrals ranged from 64% in high-intensity regions to 79% in low-intensity regions (P < 0.001). Compared with low-intensity regions, fewer physicians in high-intensity regions felt able to maintain good ongoing patient relationships (range, 62% to 70%; P < 0.001) or able to provide high-quality care (range, 72% to 77%; P = 0.009). In most cases, differences persisted but were attenuated in magnitude after adjustment for physician attributes, practice characteristics, and local market factors (for example, managed care penetration); the difference in perceived ability to provide high-quality care was no longer statistically significant (P = 0.099).
The cross-sectional design prevented demonstration of a causal relationship between intensity and physician perceptions of quality.
Despite more resources, physicians in regions of high health care intensity did not report greater ease in obtaining needed services or greater ability to provide high-quality care.
研究表明，在美国，患者病情严重程度相近的不同地区，医疗保健的使用和支出存在显著差异。尽管已发现高医疗强度地区的患者治疗效果和护理质量并不更好，但尚不清楚这些地区的医生是否比低强度地区的医生感觉自己更有能力提供良好的患者护理。
确定高医疗强度地区的医生是否比低强度地区的医生感觉自己更有能力照顾患者。
医生电话调查。
美国51个大城市和9个非大城市地区以及一个补充性全国样本。
10577名在1998年或1999年为成年人提供护理的医生参与了社区追踪研究调查（回复率为61%）。
使用临终支出指数来衡量支出，该指数反映的是所提供医疗服务总量的差异，而非疾病或价格的差异，以此确定医生所在社区的医疗保健强度。结果包括医生对临床服务可及性的感知、为患者提供高质量护理的能力以及职业满意度。
尽管高医疗强度地区人均医院病床和专科医生数量更多，但这些地区的医生报告称，为患者获取所需服务更困难。感觉能够安排选择性住院治疗的医生比例，在高医疗强度地区为50%，在最低医疗强度地区为64%（医疗强度与住院治疗可及性感知之间的关系，P<0.001）；感觉能够获得高质量专科转诊的医生比例，在高医疗强度地区为64%，在低医疗强度地区为79%（P<0.001）。与低医疗强度地区相比，高医疗强度地区感觉能够维持良好的持续患者关系的医生较少（范围为62%至70%；P<0.001），或者感觉能够提供高质量护理的医生较少（范围为72%至77%；P=0.009）。在大多数情况下，差异仍然存在，但在对医生属性、执业特征和当地市场因素（例如管理式医疗渗透率）进行调整后，差异幅度有所减小；提供高质量护理的感知能力差异不再具有统计学意义（P=0.099）。
横断面设计无法证明医疗强度与医生对质量的认知之间存在因果关系。
尽管资源更多，但高医疗强度地区的医生在获取所需服务或提供高质量护理方面，并未报告更大的便利或更强的能力。
