Institute for Clinical Evaluative Sciences, 2075 Bayview Ave., Toronto, Canada.
CJEM. 2005 Mar;7(2):100-6. doi: 10.1017/s1481803500013051.
Difficulty maintaining physician staffing in emergency departments (EDs) prompted the government of Ontario to offer alternate funding arrangements (AFAs) to replace fee-for-service remuneration for physicians working in EDs.
To analyze the effect of AFAs on physician staffing and practice patterns.
We obtained Ontario Health Insurance Program fee-for-service and shadow-billing records for all physician services provided in EDs one year before and one year after implementation of an ED AFA. Only sites with reliable billing data were retained. Physicians were assigned to small/rural, community or teaching hospital groups based on their billing claims. For each hospital type, and all hospitals combined, we compared the pre- and post-AFA periods in terms of the number of physicians working regularly in the ED and their workload. As a possible unintended consequence of AFAs, we also compared physicians' involvement in primary care.
Overall, 76.2% of eligible hospitals adopted an ED AFA, of which 49 (42.6%) were included in our study (16 small/rural, 27 community and 6 teaching hospitals). In the post-AFA period, the number of physicians working in EDs increased by 7, from 674 to 681, representing a 1.0% increase overall in the workforce (p = 0.84). The change varied by hospital type, from a 5.8% increase in teaching hospitals to a 2.2% decrease in community hospitals, though none was significant. In the post-AFA period, the number of physicians working a moderate number of days per month increased from 190 to 214, representing a 3.2% absolute increase (p = 0.39), and the number working few (<5) or many (>10) days per month decreased. Post-AFA, the number of physicians working in EDs who also provided primary care services decreased by 1.7%, from 544 to 535 (p = 0.10).
Emergency department AFAs have been widely adopted in Ontario, but have not been associated with substantial changes in the overall physician workforce in EDs. However, trends toward increased physician numbers were seen in small/rural and teaching hospitals. There was little evidence of any adverse effects on the provision of primary care services by physicians.
由于急诊科医生人力配备困难，安大略省政府提出了替代供资安排（AFAs），以取代在急诊科工作的医生的按服务收费薪酬。
分析 AFAs 对医生人力配备和实践模式的影响。
我们获取了安大略省健康保险计划所有医生在急诊科提供的按服务收费和影子计费记录，时间为实施急诊科 AFA 的前一年和后一年。仅保留计费数据可靠的地点。根据计费要求，将医生分配到小/农村、社区或教学医院组。对于每种医院类型和所有医院的组合，我们比较了 AFA 前后期间定期在急诊科工作的医生人数及其工作量。作为 AFAs 的一个可能意外后果，我们还比较了医生参与初级保健的情况。
总体而言，76.2%的合格医院采用了急诊科 AFA，其中 49 家（42.6%）被纳入我们的研究（16 家小/农村、27 家社区和 6 家教学医院）。在 AFA 后期间，在急诊科工作的医生人数增加了 7 人，从 674 人增加到 681 人，整体劳动力增加了 1.0%（p = 0.84）。这种变化因医院类型而异，从教学医院的 5.8%增加到社区医院的 2.2%减少，但都没有统计学意义。在 AFA 后期间，每月工作中等天数的医生人数从 190 人增加到 214 人，绝对增加了 3.2%（p = 0.39），每月工作天数较少（<5）或较多（>10）的医生人数减少。AFA 后，同时提供初级保健服务的急诊科医生人数减少了 1.7%，从 544 人减少到 535 人（p = 0.10）。
安大略省已广泛采用急诊科 AFA，但并未导致急诊科整体医生人数发生重大变化。然而，在小/农村和教学医院中，医生人数呈增加趋势。几乎没有证据表明医生提供初级保健服务的情况有任何不利影响。
