Department of Operations and Decision Systems, Université Laval; Canadian Centre for Health Economics; Institute of Health Policy, Management and Evaluation, University of Toronto.
Canadian Centre for Health Economics; Institute of Health Policy, Management and Evaluation, University of Toronto; Institute for Clinical Evaluative Sciences; Toronto Rehabilitation Institute.
Soc Sci Med. 2017 May;181:24-33. doi: 10.1016/j.socscimed.2017.03.040. Epub 2017 Mar 22.
The study analyzes the relationship between the risk of a hospitalization for an ambulatory care sensitive condition (ACSC), and the primary care payment and the organizational model used by the patient (fee-for-service, enhanced fee-for-service, blended capitation, blended capitation with interdisciplinary teams). The study used linked patient-level health administrative databases and census data housed at the Institute for Clinical Evaluative Sciences in Ontario. Since the province provides universal health care, the data capture all patients in Ontario, Canada's most populous province, with about 13 million inhabitants. All Ontario patients diagnosed with an ACSC prior to April 1, 2012, who had at least one visit with a physician between April 1, 2012, and March 31, 2013, were included in the study (n = 1,710,310). Each patient was assigned to the primary care model of his/her physician. The different models were categorized as Fee-for-Service (FFS), enhanced-FFS, blended capitation, and interdisciplinary team. A logistic regression was used to model the risk of having an ACSC hospitalization during the one-year observation period. Adjustments were made for patient characteristics (age, sex, health status, and socio-economic status) and for the geographic location of the practice. Using patients belonging to FFS models as the reference group, the risk of an ACSC hospitalization was higher for patients belonging to the blended-capitation model using interdisciplinary teams (Adjusted Odds Ratio [AOR] = 1.06, 95% confidence interval [CI] = 1.00-1.12) and lower for enhanced-FFS (AOR = 0.78, CI = 0.74-0.82) and blended capitation patients (AOR = 0.91, CI = 0.86-0.96). Using patients with hypertension as the reference group, the odds of an ACSC hospitalization were much higher for patients with any other ACSC and increased with patients' morbidity. The risk was lower for patients of higher socio-economic status (AOR = 0.63, CI = 0.60-0.67) in the highest neighborhood income quintile.
本研究分析了门诊保健敏感条件（ACSC）住院风险与患者的初级保健支付方式和组织模式（按服务收费、增强型按服务收费、混合人头费、混合人头费与跨学科团队）之间的关系。本研究使用了链接的患者级别的健康行政数据库和安大略省临床评估科学研究所的人口普查数据。由于该省提供全民医疗保健，该数据涵盖了加拿大人口最多的省份安大略省的所有患者，约有 1300 万居民。所有在 2012 年 4 月 1 日前被诊断患有 ACSC 的安大略省患者，且在 2012 年 4 月 1 日至 2013 年 3 月 31 日期间至少有一次与医生就诊的患者，均被纳入本研究（n=1,710,310）。每位患者被分配到其医生的初级保健模式。不同的模式被归类为按服务收费（FFS）、增强型 FFS、混合人头费和跨学科团队。使用逻辑回归模型来模拟在一年观察期内发生 ACSC 住院的风险。根据患者特征（年龄、性别、健康状况和社会经济地位）和实践地点对调整因素进行了调整。将属于 FFS 模式的患者作为参考组，属于混合人头费使用跨学科团队的患者发生 ACSC 住院的风险更高（调整后的优势比 [AOR] = 1.06，95%置信区间 [CI] = 1.00-1.12），而增强型 FFS（AOR = 0.78，CI = 0.74-0.82）和混合人头费患者的风险较低（AOR = 0.91，CI = 0.86-0.96）。以高血压患者作为参考组，任何其他 ACSC 患者发生 ACSC 住院的可能性都要高得多，并且随着患者的发病率而增加。在收入最高的五个街区中，社会经济地位较高的患者（AOR = 0.63，CI = 0.60-0.67）的风险较低。
