From Graduate School of Public Health, Department of Health Policy and Management, University of Pittsburgh.
J Am Board Fam Med. 2018 Jul-Aug;31(4):605-611. doi: 10.3122/jabfm.2018.04.170214.
Direct Primary Care (DPC), where patients pay a fee to a primary care provider to obtain access to services, is a delivery model that has received notable attention and enthusiasm from some providers. Proponents of DPC believe that the model increases accessibility, reduces overhead, and ultimately improves care for patients; however, there is little evidence in the peer-reviewed literature to support these claims. The objective of this analysis was to apply Starfield's adaptation of Donabedian's Structure-Process-Outcome conceptual model to evaluate primary care to formally display the links between potential changes in clinical structure and processes from DPC adoption. Based on existing literature on the constructs in Starfield's model, expectations of DPC's impact at the patient, clinic, and system levels were defined. DPC uses changes to financing and the population eligible to trigger potential gains in continuity and accessibility to subsequently improve care processes. There is evidence to support DPC as a theoretically sound approach to improve attributes of primary care, such as first contact care and longitudinality at the clinic level for participating patients. At the health system level, DPC has low-construct validity that would suggest a positive impact on the potentially eligible population's health due to membership fees that exclude patients who are more likely to be vulnerable and complex than patients who are willing and able to stay in the practice. Descriptive and comparative research of included and excluded patients is needed to inform providers, patients, and policy makers of the DPC's ability to attain the attributes of primary care and ultimately achieve better outcomes over alternative primary care delivery and financing models. Meanwhile, theoretic application informed by years of research on primary care provide insight as to what changes to expect and to monitor as practices consider DPC adoption.
直接初级保健（DPC），即患者向初级保健提供者支付费用以获得服务的一种交付模式，已引起一些提供者的广泛关注和热情。DPC 的支持者认为，该模式提高了可及性，降低了间接成本，并最终改善了患者的护理；然而，同行评议文献中几乎没有证据支持这些说法。本分析的目的是应用 Starfield 对 Donabedian 的结构-过程-结果概念模型的改编，对初级保健进行评估，正式展示 DPC 采用后临床结构和过程的潜在变化之间的联系。基于 Starfield 模型中现有文献中的结构，定义了对 DPC 在患者、诊所和系统层面影响的预期。DPC 通过改变融资和有资格参与的人群，有可能增加连续性和可及性，从而改善护理过程。有证据支持 DPC 作为一种理论上合理的方法，可以改善初级保健的属性，例如在诊所层面提高首次接触护理和纵向护理的质量，为参与的患者提供更好的护理。在卫生系统层面，DPC 的构建效度较低，这表明由于会员费排除了那些比愿意和能够留在实践中的患者更脆弱和复杂的患者，因此对潜在合格人群的健康可能产生积极影响。需要对包括和排除的患者进行描述性和比较性研究，以便为提供者、患者和政策制定者提供有关 DPC 实现初级保健属性的能力的信息，并最终通过替代初级保健交付和融资模式实现更好的结果。同时，基于多年来对初级保健的研究的理论应用，可以深入了解在实践考虑采用 DPC 时应期望和监测哪些变化。
