Ferrer Robert L
Department of Family and Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex, USA.
Ann Fam Med. 2007 Nov-Dec;5(6):492-502. doi: 10.1370/afm.746.
Long-term shifts in specialty choice and health workforce policy have raised concern about the future of primary care in the United States. The objective of this study was to examine current use of primary and specialty care across the US population for policy-relevant subgroups, such as disadvantaged populations and persons with chronic illness.
Data from the Medical Expenditure Panel Survey from 2004 were analyzed using a probability sample patients or other participants from the noninstitutionalized US population in 2004 (N = 34,403). The main and secondary outcome measures were the estimates of the proportion of Americans who accessed different types of primary care and specialty physicians and midlevel practitioners, as well as the fraction of ambulatory visits accounted for by the different clinician types. Data were disaggregated by income, health insurance status, race/ethnicity, rural or urban residence, and presence of 5 common chronic diseases.
Family physicians were the most common clinician type accessed by adults, seniors, and reproductive-age women, and they were second to pediatricians for children. Disadvantaged adults with 3 markers of disadvantage (poverty, disadvantaged minority, uninsured) received 45.6% (95% CI, 40.4%-50.7%) of their ambulatory visits from family physicians vs 30.5% (95% CI, 30.0%-32.1%) for adults with no markers. For children with 3 vs 0 markers of disadvantage, the proportion of visits from family physicians roughly doubled from 16.5% (95% CI, 14.4%-18.6%) to 30.1% (95% CI, 18.8%-41.2%). Family physicians constitute the only clinician group that does not show income disparities in access. Multivariate analyses show that patterns of access to family physicians and nurse-practitioners are more equitable than for other clinician types.
Primary care clinicians, especially family physicians, deliver a disproportionate share of ambulatory care to disadvantaged populations. A diminished primary care workforce will leave considerable gaps in US health care equity. Health care workforce policy should reflect this important population-level function of primary care.
专业选择和卫生人力政策的长期转变引发了对美国初级保健未来的担忧。本研究的目的是针对政策相关亚组，如弱势群体和慢性病患者，调查美国全体人口目前对初级保健和专科保健的利用情况。
使用概率抽样对2004年医疗支出面板调查的数据进行分析，样本来自2004年非机构化美国人口中的患者或其他参与者（N = 34,403）。主要和次要结局指标是对使用不同类型初级保健医生、专科医生和中级从业者的美国人比例的估计，以及不同临床医生类型占门诊就诊的比例。数据按收入、医疗保险状况、种族/族裔、农村或城市居住情况以及5种常见慢性病的患病情况进行分类。
家庭医生是成年人、老年人和育龄妇女最常就诊的临床医生类型，在儿童中仅次于儿科医生。有3个不利因素（贫困、弱势少数族裔、未参保）的弱势成年人，其门诊就诊中有45.6%（95%CI，40.4%-50.7%）是看家庭医生，而没有不利因素的成年人这一比例为30.5%（95%CI，30.0%-32.1%）。对于有3个与0个不利因素的儿童，看家庭医生的就诊比例从16.5%（95%CI，14.4%-18.6%）大致翻倍至30.1%（95%CI，18.8%-41.2%）。家庭医生是唯一在就诊机会上不存在收入差距的临床医生群体。多变量分析表明，与其他临床医生类型相比，看家庭医生和执业护士的模式更为公平。
初级保健临床医生，尤其是家庭医生，为弱势群体提供了不成比例的大量门诊护理。初级保健人力的减少将在美国医疗保健公平性方面留下巨大差距。医疗保健人力政策应反映初级保健这一重要的人群层面功能。
