Ortiz J, Wan T H
University of Central Florida, Orlando, Florida, USA.
Rural Remote Health. 2012;12:1925. Epub 2012 Feb 6.
In 2011, some 3800 Rural Health Clinics (RHCs) delivered primary care in underserved rural areas throughout the USA. To date, little research has been conducted to identify the variability in RHC performance. In an effort to address the knowledge gaps, a national, longitudinal study was conducted of a panel of 3565 RHCs. The goals of the study were to determine: (1) the relationship between two aspects of performance: efficiency and effectiveness; and (2) the factors that influence variation in RHC performance.
A non-experimental study of RHC performance was conducted using 2 years of secondary data from multiple sources. A study panel of RHCs was formed. This panel was composed of all RHCs continuously in operation during the period 2006-2007. The study panel was divided into two subsets - one for the provider-based clinics; another for the independent clinics. The individual RHC was the unit of analysis throughout the study. Descriptive statistics were calculated for each subset. Bivariate analyses was conducted of the relationships between the clinic characteristics and the performance outcome measures, as well as the interrelationships between various clinic characteristics using χ², t-tests, Cramer's V, Pearson correlation, and Spearman correlation statistics. Next, using covariance structure analysis, the interrelationships were examined among the context (community or demographic factors), design (organizational structure and other mediating factors), and performance (efficiency and effectiveness) of RHCs. Three hypotheses were tested: (1) the effectiveness of RHCs is positively influenced by efficiency; (2) there is a reciprocal relationship between RHC efficiency and effectiveness; and (3) large RHCs are more efficient than small RHCs.
To test the hypotheses that effectiveness of RHCs is positively influenced by efficiency and that there is a reciprocal relationship between efficiency and effectiveness, two covariance structure models were developed and revised: one for independent and one for provider-based RHCs. However, the revised models were not supported by the data. To test the hypothesis that large RHCs are more efficient than small ones, two additional efficiency-based structural equation models were constructed (one for independent RHCs and another for provider-based RHCs). Both of these models were supported by the data (independent model: χ² = 13.8, df = 8, p = 0.088, relative χ² = 1.723, adjusted goodness of fit index [AGFI] = .981, root mean square error of approximation [RMSEA] = .034; provider-based model: χ² = 19.011, df = 8, p = 0.015, relative χ² = 2.376, AGFI = .978, RMSEA = .043).
This study examined the relationship between efficiency and effectiveness of RHCs. In addition, it identified several factors that influence the variation in RHC performance. The study has implications for optimizing RHC performance, providing quality services to rural populations, and enhancing the value of RHC data. The present is a critical time in the history of RHCs as they transition to meet the goals and expectations of the US health system reform. Additional research is needed to quantify and trend RHCs' contribution to the rural health delivery system in order to optimize their service to rural populations.
2011年，约3800家农村医疗诊所（RHC）在美国各地医疗服务不足的农村地区提供初级医疗服务。迄今为止，几乎没有研究来确定农村医疗诊所绩效的差异。为了填补这些知识空白，对3565家农村医疗诊所组成的一个全国性纵向研究小组进行了研究。该研究的目标是确定：（1）绩效的两个方面之间的关系：效率和效果；（2）影响农村医疗诊所绩效差异的因素。
利用来自多个来源的两年二手数据对农村医疗诊所的绩效进行了非实验性研究。组建了一个农村医疗诊所研究小组。该小组由2006 - 2007年期间持续运营的所有农村医疗诊所组成。研究小组被分为两个子集——一个用于基于提供者的诊所；另一个用于独立诊所。在整个研究过程中，单个农村医疗诊所是分析单位。为每个子集计算了描述性统计数据。使用χ²检验、t检验、克莱姆相关系数V、皮尔逊相关系数和斯皮尔曼相关系数统计量，对诊所特征与绩效结果指标之间的关系以及各种诊所特征之间的相互关系进行了双变量分析。接下来，使用协方差结构分析，研究了农村医疗诊所的背景（社区或人口因素）、设计（组织结构和其他中介因素）和绩效（效率和效果）之间的相互关系。检验了三个假设：（1）农村医疗诊所的效果受到效率的正向影响；（2）农村医疗诊所的效率和效果之间存在相互关系；（3）大型农村医疗诊所比小型农村医疗诊所更有效率。
为了检验农村医疗诊所的效果受到效率的正向影响以及效率和效果之间存在相互关系的假设，开发并修订了两个协方差结构模型：一个用于独立农村医疗诊所，另一个用于基于提供者的农村医疗诊所。然而，修订后的模型未得到数据支持。为了检验大型农村医疗诊所比小型农村医疗诊所更有效率的假设，构建了另外两个基于效率的结构方程模型（一个用于独立农村医疗诊所，另一个用于基于提供者的农村医疗诊所）。这两个模型均得到数据支持（独立模型：χ² = 13.8，自由度 = 8，p = 0.088，相对χ² = 1.723，调整拟合优度指数[AGFI] = 0.981，近似均方根误差[RMSEA] = 0.034；基于提供者的模型：χ² = 19.011，自由度 = 8，p = 0.015，相对χ² = 2.376，AGFI = 0.978，RMSEA = 0.043）。
本研究考察了农村医疗诊所效率和效果之间的关系。此外，它确定了几个影响农村医疗诊所绩效差异的因素。该研究对于优化农村医疗诊所绩效、为农村人口提供优质服务以及提高农村医疗诊所数据的价值具有重要意义。当前是农村医疗诊所历史上的关键时期，因为它们正在转型以满足美国医疗体系改革的目标和期望。需要进行更多研究来量化农村医疗诊所在农村医疗服务体系中的贡献并跟踪其趋势以便优化它们为农村人口提供的服务。
