Muggah Elizabeth, Hogg William, Dahrouge Simone, Russell Grant, Kristjansson Elizabeth, Muldoon Laura, Devlin Rose Anne
C.T. Lamont Primary Health Care Research Centre, Department of Family Medicine, University of Ottawa, 43 Bruyère St, Ottawa, ON K1N 5C8.
Can Fam Physician. 2014 Jan;60(1):e24-31.
To describe patient-reported access to primary health care across 4 organizational models of primary care in Ontario, and to explore how access is associated with patient, provider, and practice characteristics.
Cross-sectional survey.
One hundred thirty-seven randomly selected primary care practices in Ontario using 1 of 4 delivery models (fee for service, established capitation, reformed capitation, and community health centres).
Patients included were at least 18 years of age, were not severely ill or cognitively impaired, were not known to the survey administrator, had consenting providers at 1 of the participating primary care practices, and were able to communicate in English or French either directly or through a translator.
Patient-reported access was measured by a 4-item scale derived from the previously validated adult version of the Primary Care Assessment Tool. Questions were asked about physician availability during and outside of regular office hours and access to health information via telephone. Responses to the scale were normalized, with higher scores reflecting greater patient-reported access. Linear regressions were used to identify characteristics independently associated with access to care.
Established capitation model practices had the highest patient-reported access, although the difference in scores between models was small. Our multilevel regression model identified several patient factors that were significantly (P = .05) associated with higher patient-reported access, including older age, female sex, good-to-excellent self-reported health, less mental health disability, and not working. Provider experience (measured as years since graduation) was the only provider or practice characteristic independently associated with improved patient-reported access.
This study adds to what is known about access to primary care. The study found that established capitation models outperformed all the other organizational models, including reformed capitation models, independent of provider and practice variables save provider experience. This suggests that the capitation models might provide better access to care and that it might take time to realize the benefits of organizational reforms.
描述安大略省4种初级保健组织模式下患者报告的初级卫生保健可及性，并探讨可及性与患者、提供者及诊疗机构特征之间的关联。
横断面调查。
安大略省137家采用4种服务模式（按服务收费、既有按人头付费、改革后的按人头付费及社区卫生中心）之一随机选取的初级保健诊疗机构。
纳入的患者年龄至少18岁，无重症或认知障碍，调查管理员不认识，在参与调查的初级保健诊疗机构之一有同意参与的提供者，且能够直接或通过翻译用英语或法语交流。
患者报告的可及性通过源自先前验证的成人版初级保健评估工具的4项量表进行测量。询问了关于正常办公时间内外的医生可及性以及通过电话获取健康信息的问题。对量表的回答进行了标准化处理，得分越高表明患者报告的可及性越高。采用线性回归确定与医疗服务可及性独立相关的特征。
既有按人头付费模式的诊疗机构患者报告的可及性最高，尽管各模式之间的得分差异较小。我们的多水平回归模型确定了几个与患者报告的较高可及性显著相关（P = .05）的患者因素，包括年龄较大、女性、自我报告健康状况良好至极佳、心理健康残疾程度较低以及未工作。提供者经验（以毕业年限衡量）是与患者报告的可及性改善独立相关的唯一提供者或诊疗机构特征。
本研究补充了有关初级保健可及性的现有知识。研究发现，既有按人头付费模式优于所有其他组织模式，包括改革后的按人头付费模式，不考虑提供者和诊疗机构变量，除了提供者经验。这表明按人头付费模式可能提供更好的医疗服务可及性，并且可能需要时间来实现组织改革的益处。
