Petersen Laura A, Woodard Lechauncy D, Henderson Louise M, Urech Tracy H, Pietz Kenneth
MPH, Health Services Research and Development (152), Houston Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX 77030, USA.
Circulation. 2009 Jun 16;119(23):2978-85. doi: 10.1161/CIRCULATIONAHA.108.836544. Epub 2009 Jun 1.
There is concern that performance measures, patient ratings of their care, and pay-for-performance programs may penalize healthcare providers of patients with multiple chronic coexisting conditions. We examined the impact of coexisting conditions on the quality of care for hypertension and patient perception of overall quality of their health care.
We classified 141 609 veterans with hypertension into 4 condition groups: those with hypertension-concordant (diabetes mellitus, ischemic heart disease, dyslipidemia) and/or -discordant (arthritis, depression, chronic obstructive pulmonary disease) conditions or neither. We measured blood pressure control at the index visit, overall good quality of care for hypertension, including a follow-up interval, and patient ratings of satisfaction with their care. Associations between condition type and number of coexisting conditions on receipt of overall good quality of care were assessed with logistic regression. The relationship between patient assessment and objective measures of quality was assessed. Of the cohort, 49.5% had concordant-only comorbidities, 8.7% had discordant-only comorbidities, 25.9% had both, and 16.0% had none. Odds of receiving overall good quality after adjustment for age were higher for those with concordant comorbidities (odds ratio, 1.78; 95% confidence interval, 1.70 to 1.87), discordant comorbidities (odds ratio, 1.32; 95% confidence interval, 1.23 to 1.41), or both (odds ratio, 2.25; 95% confidence interval, 2.13 to 2.38) compared with neither. Findings did not change after adjustment for illness severity and/or number of primary care and specialty care visits. Patient assessment of quality did not vary by the presence of coexisting conditions and was not related to objective ratings of quality of care.
Contrary to expectations, patients with greater complexity had higher odds of receiving high-quality care for hypertension. Subjective ratings of care did not vary with the presence or absence of comorbid conditions. Our findings should be reassuring to those who care for the most medically complex patients and are concerned that they will be penalized by performance measures or patient ratings of their care.
人们担心绩效指标、患者对其医疗服务的评分以及按绩效付费计划可能会对患有多种慢性并存疾病的患者的医疗服务提供者进行处罚。我们研究了并存疾病对高血压护理质量以及患者对其整体医疗质量认知的影响。
我们将141609名患有高血压的退伍军人分为4个疾病组：患有与高血压相符（糖尿病、缺血性心脏病、血脂异常）和/或不相符（关节炎、抑郁症、慢性阻塞性肺疾病）疾病的患者，或两者都没有的患者。我们在首次就诊时测量血压控制情况、高血压整体优质护理情况（包括随访间隔）以及患者对其护理的满意度评分。使用逻辑回归评估疾病类型和并存疾病数量与接受整体优质护理之间的关联。评估患者评估与客观护理质量指标之间的关系。在该队列中，49.5%的患者仅患有相符的合并症，8.7%的患者仅患有不相符的合并症，25.9%的患者两者都有，16.0%的患者两者都没有。在调整年龄后，患有相符合并症的患者接受整体优质护理的几率更高（优势比为1.78；95%置信区间为1.70至1.87），患有不相符合并症的患者（优势比为1.32；95%置信区间为1.23至1.41），或两者都有的患者（优势比为2.25；95%置信区间为2.13至2.38），相比之下两者都没有的患者几率更低。在调整疾病严重程度和/或初级保健和专科就诊次数后，研究结果没有改变。患者对护理质量的评估并未因是否存在并存疾病而有所不同，且与护理质量的客观评分无关。
与预期相反，病情更复杂的患者接受高血压优质护理的几率更高。护理的主观评分不会因是否存在合并症而有所不同。我们的研究结果应该会让那些照顾医疗最复杂患者且担心他们会因绩效指标或患者对其护理的评分而受到处罚的人感到安心。
