Brook R H, Kamberg C J, Lohr K N, Goldberg G A, Keeler E B, Newhouse J P
Department of Medicine, University of California, Los Angeles.
Med Care. 1990 May;28(5):392-433.
In this report the data from medical history questionnaires, screening examinations, insurance claims, and a face-to-face physician interview were used to examine the quality of ambulatory care received for 17 chronic conditions by a general population of 5986 adults (less than or equal to 65) and children (less than or equal to 14) enrolled in the RAND Health Insurance Experiment. Subjects in six U.S. sites were randomly assigned to insurance plans that were free or that required cost sharing, or in one site to an HMO. Quality-of-care criteria--both process (what was done to patients) and outcome (what happened to them)--were developed. Overall, 81% of outcome criteria and 62% of process criteria were met. Physicians interviewed patients with selected conditions at the Experiment's end to evaluate care. They suggested that approximately 70% of patients should have their current therapy changed, but only 30% of patients would obtain more than minor improvement from such a change. Clinically meaningful plan differences in quality of care were observed only for the process criteria dealing with the need for a visit (free plan compliance 59%; cost sharing compliance 52%). Quality of care for the poor was slightly worse than for the nonpoor and persons randomized to an HMO had slightly better overall quality of care than those in the fee-for-service system. Substantial improvements in the quality of the process of care could be made, but impact on outcome may be small. Results of the analysis suggest the need for development of clinical models to test the relationship between specific process criteria and improvements in outcome.
在本报告中，来自病史调查问卷、筛查检查、保险理赔以及医生面对面访谈的数据，被用于检验参与兰德健康保险实验的5986名成年人（小于或等于65岁）和儿童（小于或等于14岁）的普通人群，针对17种慢性病所接受的门诊护理质量。美国六个地点的受试者被随机分配到免费或需要分担费用的保险计划，或在一个地点被分配到健康维护组织（HMO）。制定了护理质量标准，包括过程标准（对患者做了什么）和结果标准（患者发生了什么）。总体而言，81%的结果标准和62%的过程标准得到了满足。在实验结束时，医生对患有特定疾病的患者进行了访谈以评估护理情况。他们认为大约70%的患者应该改变当前的治疗方法，但只有30%的患者会因这种改变而获得超过轻微改善的效果。仅在处理就诊需求的过程标准方面观察到了具有临床意义的护理质量计划差异（免费计划依从性为59%；费用分担依从性为52%）。穷人的护理质量略低于非穷人，随机分配到健康维护组织的人的总体护理质量略高于按服务收费系统中的人。护理过程质量可以有实质性的改善，但对结果的影响可能很小。分析结果表明需要开发临床模型来测试特定过程标准与结果改善之间的关系。
