Gardner Karen, Davies G Powell, Edwards Karen, McDonald Julie, Findlay Terry, Kearns Rachael, Joshi Chandni, Harris Mark
Centre for Primary Health Care and Equity, 3rd Floor AGSM Building, University of New South Wales, NSW 2052, Australia.
Aust J Prim Health. 2016;22(1):40-49. doi: 10.1071/PY15148.
The aim of this systematic review was to assess evidence of the impact of commissioning on health service use, quality, outcomes and value for money and to consider findings in the Australian context. Systematic searches of the literature identified 444 papers and, after exclusions, 36 were subject to full review. The commissioning cycle (planning, contracting, monitoring) formed a framework for analysis and impacts were assessed at individual, subpopulation and population levels. Little evidence of the effectiveness of commissioning at any level was available and observed impacts were highly context-dependent. There was insufficient evidence to identify a preferred model. Lack of skills and capacity were cited as major barriers to the implementation of commissioning. Successful commissioning requires a clear policy framework of national and regional priorities that define agreed targets for commissioning agencies. Engagement of consumers and providers, especially physicians, was considered to be critically important but is time consuming and has proven difficult to sustain. Adequate information on the cost, volume and quality of healthcare services is critically important for setting priorities, and for contracting and monitoring performance. Lack of information resulted in serious problems. High-quality nationally standardised performance measures and data requirements need to be built into contracts and ongoing monitoring and evaluation. In Australia, there is significant work to be done in areas of policy and governance, funding systems and incentives, patient enrolment or registration, information systems, individual and organisational capacity, community engagement and experience in commissioning.
本系统评价的目的是评估委托（医疗服务）对医疗服务利用、质量、结果及性价比的影响的证据，并探讨澳大利亚背景下的研究结果。对文献进行系统检索后共识别出444篇论文，排除相关论文后，36篇进入全面评价阶段。委托（医疗服务）周期（规划、签约、监测）构成了分析框架，并在个体、亚人群和总体层面评估影响。几乎没有证据表明委托（医疗服务）在任何层面有效，且观察到的影响高度依赖具体情况。没有足够的证据来确定首选模式。缺乏技能和能力被认为是实施委托（医疗服务）的主要障碍。成功的委托（医疗服务）需要一个明确的国家和地区优先事项政策框架，该框架为委托机构确定商定的目标。消费者和提供者，尤其是医生的参与被认为至关重要，但这既耗时又难以持续。关于医疗服务成本、数量和质量的充分信息对于确定优先事项以及签约和监测绩效至关重要。信息不足导致了严重问题。合同以及持续的监测和评估中需要纳入高质量的国家标准绩效指标和数据要求。在澳大利亚，在政策与治理、资金系统与激励措施、患者登记或注册、信息系统、个人和组织能力、社区参与以及委托（医疗服务）经验等领域还有大量工作要做。
