Tandjung Ryan, Morell Seraina, Hanhart Andreas, Haefeli Andreas, Valeri Fabio, Rosemann Thomas, Senn Oliver
Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland.
Private Primary Care Practice, Wetzikon, Switzerland.
PLoS One. 2017 Nov 7;12(11):e0186307. doi: 10.1371/journal.pone.0186307. eCollection 2017.
Studies have shown large variation of referral probabilities in different countries, and many influencing factors have been described. This variation is most likely explained by different healthcare systems, particularly to which extent primary care physicians (PCPs) act as gatekeepers. In Switzerland no mandatory gatekeeping system exists, however insurance companies offer voluntary managed care plans with reduced insurance premiums. We aimed at investigating the role of managed care plans as a potential referral determinant in a non-gatekeeping healthcare system. We conducted a cross-sectional study with 90 PCPs collecting data on consultations and referrals in 2012/2013. During each consultation up to six reasons for encounters (RFE) were documented. For each RFE PCPs indicated whether a referral was initiated. Determinants for referrals were analyzed by hierarchical logistic regression, taking the potential cluster effect of the PCP into account. To further investigate the independent association of the managed care plan with the referral probability, a hierarchical multivariate logistic regression model was applied, taking into account all available data potentially affecting the referring decision. PCPs collected data on 24'774 patients with 42'890 RFE, of which 2427 led to a referral. 37.5% of patients were insured in managed health care plans. Univariate analysis showed significant higher referral rates of patients with managed care plans (10.7% vs. 8.5%). The difference in referral probability remained significant after controlling for other confounders in the hierarchical multivariate regression model (OR 1.355). Patients in managed care plans were more likely to be referred than patients without such a model. These data contradict the argument that patients in managed care plans have limited healthcare access, but underline the central role of PCPs as coordinator of care.
研究表明，不同国家的转诊概率存在很大差异，并且已经描述了许多影响因素。这种差异很可能是由不同的医疗保健系统造成的，特别是初级保健医生（PCP）作为守门人的程度。在瑞士，不存在强制性的守门制度，然而保险公司提供了保费降低的自愿性管理式医疗计划。我们旨在调查管理式医疗计划在非守门医疗保健系统中作为潜在转诊决定因素的作用。我们对90名初级保健医生进行了一项横断面研究，收集了2012/2013年会诊和转诊的数据。在每次会诊期间，记录了多达六个就诊原因（RFE）。对于每个RFE，初级保健医生指出是否启动了转诊。通过分层逻辑回归分析转诊的决定因素，同时考虑初级保健医生的潜在聚类效应。为了进一步研究管理式医疗计划与转诊概率之间的独立关联，应用了分层多变量逻辑回归模型，考虑了所有可能影响转诊决定的可用数据。初级保健医生收集了24774名患者的42890个RFE数据，其中2427个导致了转诊。37.5%的患者参加了管理式医疗计划。单因素分析显示，参加管理式医疗计划的患者转诊率显著更高（10.7%对8.5%）。在分层多变量回归模型中控制其他混杂因素后，转诊概率的差异仍然显著（OR 1.355）。参加管理式医疗计划的患者比没有这种模式的患者更有可能被转诊。这些数据与参加管理式医疗计划的患者获得医疗保健机会有限的观点相矛盾，但强调了初级保健医生作为护理协调员的核心作用。
