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谁能通过集中等候名单获得家庭医生服务?

Who gets a family physician through centralized waiting lists?

作者信息

Breton Mylaine, Brousselle Astrid, Boivin Antoine, Roberge Danièle, Pineault Raynald, Berbiche Djamal

机构信息

Charles-LeMoyne Hospital Research Centre, Longueuil Campus, 150 Place Charles-LeMoyne, Room 200, Longueuil, J4L 0A8, , Quebec, Canada.

Université de Sherbrooke, Sherbrooke, Quebec, Canada.

出版信息

BMC Fam Pract. 2015 Feb 5;16:10. doi: 10.1186/s12875-014-0220-7.

Abstract

BACKGROUND

North American patients are experiencing difficulties in securing affiliations with family physicians. Centralized waiting lists are increasingly being used in Organisation for Economic Co-operation and Development countries to improve access. In 2011, the Canadian province of Quebec introduced new financial incentives for family physicians' enrolment of orphan patients through centralized waiting lists, the Guichet d'accès aux clientèles orphelines, with higher payments for vulnerable patients. This study analyzed whether any significant changes were observed in the numbers of patient enrolments with family physicians' after the introduction of the new financial incentives. Prior to then, financial incentives had been offered for enrolment of vulnerable patients only and there were no incentives for enrolling non-vulnerable patients. After 2011, financial incentives were also offered for enrolment of non-vulnerable patients, while those for enrolment of vulnerable patients were doubled.

METHODS

A longitudinal quantitative analysis spanning a five-year period (2008-2013) was performed using administrative databases covering all patients enrolled with family physicians through centralized waiting lists in the province of Quebec (n = 494,697 patients). Mixed regression models for repeated-measures were used.

RESULTS

The number of patients enrolled with a family physician through centralized waiting lists more than quadrupled after the changes in financial incentives. Most of this increase involved non-vulnerable patients. After the changes, 70% of patients enrolled with a family physician through centralized waiting lists were non-vulnerable patients, most of whom had been referred to the centralized waiting lists by the physician who enrolled them, without first being registered in those lists or having to wait because of their priority level.

CONCLUSION

Centralized waiting lists linked to financial incentives increased the number of family physicians' patient enrolments. However, although vulnerable patients were supposed to be given precedence, physicians favoured enrolment of healthier patients over those with greater health needs and higher assessed priority. These results suggest that introducing financial incentives without appropriate regulations may lead to opportunistic use of the incentive system with unintended policy consequences.

摘要

背景

北美患者在与家庭医生建立联系方面面临困难。经济合作与发展组织国家越来越多地使用集中等候名单来改善就医机会。2011年,加拿大魁北克省推出了新的经济激励措施,鼓励家庭医生通过集中等候名单(即“孤儿患者接入窗口”)接收孤儿患者,对弱势患者给予更高报酬。本研究分析了新经济激励措施实施后,家庭医生接收的患者人数是否有显著变化。在此之前,仅对接收弱势患者提供经济激励,对接收非弱势患者没有激励措施。2011年后,对接收非弱势患者也提供经济激励,而对接收弱势患者的激励增加了一倍。

方法

利用涵盖魁北克省通过集中等候名单注册在家庭医生名下的所有患者(n = 494,697例患者)的行政数据库,进行了一项为期五年(2008 - 2013年)的纵向定量分析。使用了重复测量的混合回归模型。

结果

经济激励措施改变后,通过集中等候名单注册在家庭医生名下的患者人数增加了四倍多。这种增加主要涉及非弱势患者。改变后,通过集中等候名单注册在家庭医生名下的患者中,70%是非弱势患者,其中大多数是由接收他们的医生转诊到集中等候名单的,他们没有首先在这些名单上登记,也没有因为优先级而必须等待。

结论

与经济激励挂钩的集中等候名单增加了家庭医生接收的患者人数。然而,尽管弱势患者本应享有优先权,但医生更倾向于接收健康状况较好的患者,而非健康需求更大、评估优先级更高的患者。这些结果表明,在没有适当监管的情况下引入经济激励措施可能会导致对激励系统的投机性利用,产生意想不到的政策后果。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/b195/4328670/42a5554fe2f1/12875_2014_220_Fig1_HTML.jpg

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