Udvarhelyi I S, Jennison K, Phillips R S, Epstein A M
Brigham and Women's Hospital, Beth Israel Hospital, Harvard Medical School, Harvard School of Public Health, Boston, Massachusetts.
Ann Intern Med. 1991 Sep 1;115(5):394-400. doi: 10.7326/0003-4819-115-5-394.
To determine whether the quality of care for common ambulatory conditions is adversely affected when physicians are provided with incentives to limit the use of health services.
Retrospective cohort study over a 2-year period.
Four group practices that cared for both fee-for-service patients and prepaid patients within a network model health maintenance organization (HMO).
Equal numbers of prepaid (HMO) and fee-for-service patients were selected by randomly choosing medical records from each group practice: 246 patients with chronic uncomplicated hypertension and 250 women without chronic diseases who received preventive care.
Adequate hypertension control was defined as a mean blood pressure of less than 150/90. Adequate preventive care was defined as the provision of blood pressure screening, colon cancer screening, breast cancer screening, and cervical cancer screening within guidelines recommended by the 1989 U.S. Preventive Services Task Force. Resource use was measured by the annual number of visits and tests.
The adjusted relative odds of HMO patients having controlled hypertension, compared with fee-for-service patients, were 1.82 (95% CI, 1.02 to 3.27). The relative risks of HMO patients receiving preventive care within established guidelines were 1.19 (CI, 0.93 to 1.51) for colon cancer screening, 1.78 (CI, 1.11 to 2.84) for annual breast examinations, 1.75 (CI, 1.08 to 2.84) for biannual mammography, and 1.35 (CI, 1.13 to 1.60) for Papanicolaou smears every 3 years. Prepaid patients had visit rates that were 18% to 22% higher than those of fee-for-service patients.
In the type of network model HMO we studied, the quality and quantity of ambulatory care for HMO patients was equal to or better than that for fee-for-service patients. In this setting, the incentives for physicians to limit resource use may be offset by lack of disincentives for HMO patients to seek care.
确定当医生受到限制医疗服务使用的激励措施时，常见门诊疾病的护理质量是否会受到不利影响。
为期2年的回顾性队列研究。
在一个网络模式的健康维护组织（HMO）中，有四家为按服务收费患者和预付费患者提供护理的团体诊所。
通过从每个团体诊所随机选择病历，选取了数量相等的预付费（HMO）患者和按服务收费患者：246例患有慢性单纯性高血压的患者以及250例接受预防性护理的无慢性病女性。
血压控制良好定义为平均血压低于150/90。充分的预防性护理定义为按照1989年美国预防服务工作组推荐的指南提供血压筛查、结肠癌筛查、乳腺癌筛查和宫颈癌筛查。资源使用情况通过年度就诊次数和检查次数来衡量。
与按服务收费患者相比，HMO患者血压得到控制的调整后相对比值为1.82（95%可信区间，1.02至3.27）。HMO患者在既定指南内接受预防性护理的相对风险分别为：结肠癌筛查为1.19（可信区间，0.93至1.51），年度乳房检查为1.78（可信区间，1.11至2.84），每两年一次乳房X光检查为1.75（可信区间，1.08至2.84），每三年一次巴氏涂片检查为1.35（可信区间，1.13至1.60）。预付费患者的就诊率比按服务收费患者高18%至22%。
在我们研究的这种网络模式HMO中，HMO患者的门诊护理质量和数量与按服务收费患者相当或更好。在这种情况下，医生限制资源使用的激励措施可能会被HMO患者寻求护理时缺乏抑制措施所抵消。
