Department of Health Management and Economics, School of Public Health, Tehran, Iran.
PLoS One. 2012;7(8):e41988. doi: 10.1371/journal.pone.0041988. Epub 2012 Aug 24.
Despite the importance of health care fraud and the political, legislative and administrative attentions paid to it, combating fraud remains a challenge to the health systems. We aimed to identify, categorize and assess the effectiveness of the interventions to combat health care fraud and abuse.
The interventions to combat health care fraud can be categorized as the interventions for 'prevention' and 'detection' of fraud, and 'response' to fraud. We conducted sensitive search strategies on Embase, CINAHL, and PsycINFO from 1975 to 2008, and Medline from 1975-2010, and on relevant professional and organizational websites. Articles assessing the effectiveness of any intervention to combat health care fraud were eligible for inclusion in our review. We considered including the interventional studies with or without a concurrent control group. Two authors assessed the studies for inclusion, and appraised the quality of the included studies. As a limited number of studies were found, we analyzed the data using narrative synthesis.
The searches retrieved 2229 titles, of which 221 full-text studies were assessed. We found no studies using an RCT design. Only four original articles (from the US and Taiwan) were included: two studies within the detection category, one in the response category, one under the detection and response categories, and no studies under the prevention category. The findings suggest that data-mining may improve fraud detection, and legal interventions as well as investment in anti-fraud activities may reduce fraud.
Our analysis shows a lack of evidence of effect of the interventions to combat health care fraud. Further studies using robust research methodologies are required in all aspects of dealing with health care fraud and abuse, assessing the effectiveness and cost-effectiveness of methods to prevent, detect, and respond to fraud in health care.
尽管医疗保健欺诈的重要性以及政治、立法和行政部门对其的关注，打击欺诈仍然是卫生系统面临的挑战。我们旨在确定、分类和评估打击医疗保健欺诈和滥用的干预措施的有效性。
打击医疗保健欺诈的干预措施可分为预防和检测欺诈的干预措施，以及对欺诈的反应干预措施。我们在 Embase、CINAHL 和 PsycINFO 上进行了敏感的搜索策略，时间范围为 1975 年至 2008 年，在 Medline 上进行了搜索，时间范围为 1975 年至 2010 年，同时还在相关的专业和组织网站上进行了搜索。评估任何打击医疗保健欺诈的干预措施有效性的文章都有资格纳入我们的审查。我们考虑纳入有或没有对照的干预性研究。两位作者对纳入的研究进行了评估，并评估了纳入研究的质量。由于发现的研究数量有限，我们使用叙述性综合分析来分析数据。
搜索共检索到 2229 个标题，其中有 221 篇全文研究进行了评估。我们没有发现使用 RCT 设计的研究。仅纳入了四项原始文章（来自美国和中国台湾）：两项检测类别研究，一项反应类别研究，一项检测和反应类别研究，以及一项预防类别研究。研究结果表明，数据挖掘可能会提高欺诈检测的效果，而法律干预以及对反欺诈活动的投资可能会减少欺诈行为。
我们的分析表明，打击医疗保健欺诈的干预措施缺乏效果证据。在处理医疗保健欺诈和滥用的各个方面，需要使用稳健的研究方法进一步开展研究，评估预防、检测和应对医疗保健欺诈的方法的有效性和成本效益。
