Burström Bo, Burström Kristina, Nilsson Gunnar, Tomson Göran, Whitehead Margaret, Winblad Ulrika
Department of Public Health Sciences, Equity and Health Policy Research Group, Karolinska Institutet, SE 171 77, Stockholm, Sweden.
Department of Learning, Informatics, Management and Ethics, Health Outcomes and Economic Evaluation Research Group, Karolinska Institutet, Stockholm, Sweden.
Int J Equity Health. 2017 Jan 28;16(1):29. doi: 10.1186/s12939-017-0524-z.
Good health and equal health care are the cornerstones of the Swedish Health and Medical Service Act. Recent studies show that the average level of health, measured as longevity, improves in Sweden, however, social inequalities in health remain a major issue. An important issue is how health care services can contribute to reducing inequalities in health, and the impact of a recent Primary Health Care (PHC) Choice Reform in this respect. This paper presents the findings of a review of the existing evidence on impacts of these reforms.
We reviewed the published accounts (reports and scientific articles) which reported on the impact of the Swedish PHC Choice Reform of 2010 and changes in reimbursement systems, using Donabedian's framework for assessing quality of care in terms of structure, process and outcomes.
Since 2010, over 270 new private PHC practices operating for profit have been established throughout the country. One study found that the new establishments had primarily located in the largest cities and urban areas, in socioeconomically more advantaged populations. Another study, adjusting for socioeconomic composition found minor differences. The number of visits to PHC doctors has increased, more so among those with lesser needs of health care. The reform has had a negative impact on the provision of services for persons with complex needs. Opinions of doctors and staff in PHC are mixed, many state that persons with lesser needs are prioritized. Patient satisfaction is largely unchanged. The impact of PHC on population health may be reduced.
The PHC Choice Reform increased the average number of visits, but particularly among those in more affluent groups and with lower health care needs, and has made integrated care for those with complex needs more difficult. Resource allocation to PHC has become more dependent on provider location, patient choice and demand, and less on need of care. On the available evidence, the PHC Choice Reform may have damaged equity of primary health care provision, contrary to the tenets of the Swedish Health and Medical Service Act. This situation needs to be carefully monitored.
良好的健康状况和平等的医疗保健是瑞典《健康与医疗服务法》的基石。近期研究表明，以寿命衡量的瑞典平均健康水平有所提高，然而，健康方面的社会不平等仍是一个主要问题。一个重要问题是医疗保健服务如何能够有助于减少健康方面的不平等，以及近期初级医疗保健（PHC）选择改革在这方面的影响。本文介绍了对这些改革影响的现有证据进行综述的结果。
我们使用多纳贝迪安评估医疗质量的框架（从结构、过程和结果方面），对已发表的报告（报告和科学文章）进行了综述，这些报告阐述了2010年瑞典初级医疗保健选择改革的影响以及报销制度的变化。
自2010年以来，全国已建立了270多家以盈利为目的的新的私立初级医疗保健机构。一项研究发现，新机构主要位于最大的城市和市区，服务于社会经济条件更优越的人群。另一项根据社会经济构成进行调整的研究发现差异较小。看初级医疗保健医生的就诊次数有所增加，需求较低的人群增加得更多。该改革对有复杂需求者的服务提供产生了负面影响。初级医疗保健医生和工作人员的意见不一，许多人表示需求较低的人被优先考虑。患者满意度基本未变。初级医疗保健对人群健康的影响可能会降低。
初级医疗保健选择改革增加了平均就诊次数，但特别是在更富裕群体和医疗保健需求较低的人群中，并且使为有复杂需求者提供综合护理变得更加困难。初级医疗保健的资源分配变得更加依赖于提供者的位置、患者的选择和需求，而较少依赖于护理需求。根据现有证据，初级医疗保健选择改革可能损害了初级医疗保健提供的公平性，这与瑞典《健康与医疗服务法》的宗旨相悖。这种情况需要仔细监测。
