Fihn S D, Wicher J B
Department of Medicine, University of Washington, Seattle.
J Gen Intern Med. 1988 Jul-Aug;3(4):356-62. doi: 10.1007/BF02595794.
In 1983 a budget shortfall at the Seattle Veterans Administration Medical Center prompted termination of regular outpatient care for individuals of low legal priority deemed medically stable by administrative criteria. The authors examined the effects on health status and access to medical care of 157 discharged patients and 74 comparison subjects who met the discharge criteria but were retained. Seventeen months after termination, 41% of discharged patients reported their self-perceived health status was "much worse," compared with 8% of retained patients (p less than 0.001). Among discharged patients, 23% had seen no health care provider, 58% believed they lacked access to necessary care, and 47% had reduced prescribed medications. In contrast, all retained patients had seen a provider, 5% claimed to lack access, and 25% had reduced medications. Among discharged patients for whom complete follow-up data were available, the percentage whose blood pressures were out of control at their 13-month follow-up visits was 41%, compared with 5% at the time of discharge. This marked change contrasted with a rise from 9% to 17% among retained patients. A best-case/worse-case analysis indicated that the findings could not be fully explained by biased follow-up. Administrative criteria did not accurately identify medically stable patients. During the study interval 25% of discharged patients were hospitalized and at least 6% died. These findings suggest that federal health care programs are important to many indigent patients and that withdrawing services may have deleterious consequences.
1983年，西雅图退伍军人管理局医疗中心的预算短缺促使其终止了对那些根据行政标准被认定为病情稳定但法律优先级较低的个人的常规门诊治疗。作者研究了157名出院患者以及74名符合出院标准但被留院观察的对照对象的健康状况和医疗服务获取情况受到的影响。在治疗终止17个月后，41%的出院患者报告称他们自我感觉的健康状况“差得多”，而留院患者中这一比例为8%（p值小于0.001）。在出院患者中，23%的人未看过任何医疗服务提供者，58%的人认为他们无法获得必要的治疗，47%的人减少了处方药用量。相比之下，所有留院患者都看过医疗服务提供者，5%的人声称无法获得治疗，25%的人减少了用药量。在有完整随访数据的出院患者中，13个月随访时血压失控的患者比例为41%，而出院时这一比例为5%。这一显著变化与留院患者中该比例从9%升至17%形成对比。一项最佳情况/最差情况分析表明，这些结果不能完全用有偏差的随访来解释。行政标准未能准确识别出病情稳定的患者。在研究期间，25%的出院患者住院治疗，至少6%的患者死亡。这些发现表明，联邦医疗保健计划对许多贫困患者很重要，取消服务可能会产生有害后果。
