Ruhnke Gregory W, Manning Willard G, Rubin David T, Meltzer David O
G.W. Ruhnke is assistant professor, Section of Hospital Medicine, Department of Medicine, University of Chicago Medicine, Chicago, Illinois.W.G. Manning was professor, Department of Health Studies, and professor, Public Policy Studies and Public Health Sciences, Harris School of Public Policy Studies, University of Chicago, Chicago, Illinois.D.T. Rubin is professor of medicine and section chief, Gastroenterology, Hepatology and Nutrition, Department of Medicine, Pritzker School of Medicine, University of Chicago Medicine, Chicago, Illinois.D.O. Meltzer is section chief, Hospital Medicine, Fanny L. Pritzker Professor of Medicine, and director, Center for Health and the Social Sciences, Pritzker School of Medicine, and professor, Harris School of Public Policy Studies, University of Chicago, Chicago, Illinois.
Acad Med. 2017 May;92(5):703-708. doi: 10.1097/ACM.0000000000001500.
Because the effect of physician supply on utilization remains controversial, literature based on non-Medicare populations is sparse, and a physician supply expansion is under way, the potential for physician-induced demand across diverse populations is important to understand. A substantial proportion of gastrointestinal endoscopies may be inappropriate. The authors analyzed the impact of physician supply, practice patterns, and clinical history on esophagogastroduodenoscopy (EGD, defined as discretionary) among patients hospitalized with lower gastrointestinal bleeding (LGIB).
Among 34,344 patients hospitalized for LGIB from 2004 to 2009, 43.1% and 21.3% had a colonoscopy or EGD, respectively, during the index hospitalization or within 6 months after. Linking to the Dartmouth Atlas via patients' hospital referral region, gastroenterologist density and hospital care intensity (HCI) index were ascertained. Adjusting for age, gender, comorbidities, and race/education indicators, the association of gastroenterologist density, HCI index, and history of upper gastrointestinal disease with EGD was estimated using logistic regression.
EGD was not associated with gastroenterologist density or HCI index, but was associated with a history of upper gastrointestinal disease (OR 2.30; 95% CI 2.17-2.43), peptic ulcer disease (OR 4.82; 95% CI 4.26-5.45), and liver disease (OR 1.34; 95% CI 1.18-1.54).
Among patients hospitalized with LGIB, large variation in gastroenterologist density did not predict EGD, but relevant clinical history did, with association strengths commensurate with risk for upper gastrointestinal bleeding. In the scenario studied, no evidence was found that specialty physician supply increases will result in more discretionary care within commercially insured populations.
由于医生供给对医疗服务利用的影响仍存在争议，基于非医疗保险人群的相关文献较少，且医生供给正在扩张，因此了解不同人群中医生诱导需求的可能性很重要。相当一部分胃肠道内窥镜检查可能并不恰当。作者分析了医生供给、执业模式和临床病史对因下消化道出血（LGIB）住院患者进行食管胃十二指肠镜检查（EGD，定义为可自由决定的检查）的影响。
在2004年至2009年因LGIB住院的34344例患者中，分别有43.1%和21.3%在本次住院期间或出院后6个月内接受了结肠镜检查或EGD。通过患者的医院转诊地区与达特茅斯地图集建立联系，确定胃肠病医生密度和医院护理强度（HCI）指数。在对年龄、性别、合并症和种族/教育指标进行调整后，使用逻辑回归估计胃肠病医生密度、HCI指数和上消化道疾病史与EGD之间的关联。
EGD与胃肠病医生密度或HCI指数无关，但与上消化道疾病史（比值比[OR]2.30；95%置信区间[CI]2.17 - 2.43）、消化性溃疡疾病（OR 4.82；95% CI 4.26 - 5.45）和肝病（OR 1.34；95% CI 1.18 - 1.54）有关。
在因LGIB住院的患者中，胃肠病医生密度的巨大差异并不能预测EGD，但相关临床病史可以，其关联强度与上消化道出血风险相当。在所研究的情况下，没有证据表明专科医生供给增加会导致商业保险人群中更多的可自由决定的医疗服务。
