Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania.
Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, Farmington.
JAMA Netw Open. 2024 Sep 3;7(9):e2434347. doi: 10.1001/jamanetworkopen.2024.34347.
Many teaching hospitals in the US segregate patients by insurance status, with resident clinics primarily composed of publicly insured or uninsured patients and faculty practices seeing privately insured patients. The prevalence of this model in obstetrics and gynecology residencies is unknown.
To examine the prevalence of payer-based segregation in obstetrics and gynecology residency ambulatory care sites nationally and to compare residents' and program directors' perceptions of differences in quality of care between payer-segregated and integrated sites.
DESIGN, SETTING, AND PARTICIPANTS: This national survey study included all 6060 obstetrics and gynecology residents and 293 obstetrics and gynecology residency program directors in the US as of January 2023. The proportion of program directors reporting payer segregation was calculated to characterize the national prevalence of this model in obstetrics and gynecology. Perceived differences in care quality were compared between residents and program directors at payer-segregated sites.
The primary measure was prevalence of payer-based segregation in obstetrics and gynecology residency programs in the US as reported by residency program directors. The secondary measure was resident and program director perceptions of care quality in these ambulatory care settings. Before study initiation, the study hypothesis was that residents and program directors at ambulatory sites with payer-based segregation would report more disparity in perceived health care quality between resident and faculty practices compared with those from integrated sites.
A total of 251 residency program directors (response rate, 85.7%) and 3471 residents (response rate, 57.3%) were included in the study. Resident respondent demographics reflected demographics of obstetrics and gynecology residents nationally in terms of racial and ethnic distribution (6 [0.2%] American Indian or Alaska Native; 425 [13.0%] Asian; 239 [7.3%] Black or African American; 290 [8.9%] Hispanic, Latinx, or Spanish; 7 [0.2%] Native Hawaiian or Other Pacific Islander; 2052 [62.7%] non-Hispanic White; 49 [1.5%] multiracial; 56 [1.7%] other [any race not listed]; and 137 [4.2%] preferred not to say) and geographic distribution (regional prevalence of payer-based segregation: 36 of 53 [67.9%] in the Northeast, 35 of 44 [79.5%] in the Midwest, 43 of 67 [64.2%] in the South, and 13 of 22 [59.1%] in the West), with 2837 respondents (86.9%) identifying as female. Among program directors, 127 (68.3%) reported payer-based segregation in ambulatory care. University programs were more likely to report payer-based segregation compared with community, hybrid, and military programs (63 of 85 [74.1%] vs 31 of 46 [67.4%], 32 of 51 [62.7%], and 0, respectively; P = .04). Residents at payer-segregated programs were less likely than their counterparts at integrated programs to report equal or higher care quality from residents compared with faculty (1662 [68.7%] vs 692 [81.6%] at segregated and integrated programs, respectively; P < .001).
In this survey study of residents and residency program directors, payer-based segregation was prevalent in obstetrics and gynecology residency programs, particularly at university programs. These findings reveal an opportunity for structural reform to promote more equitable care in residency training programs.
重要性：美国许多教学医院根据保险状况将患者分开，住院医生诊所主要由公共保险或无保险患者组成，教职员工诊所则为私人保险患者提供服务。这种模式在妇产科住院医师培训中的流行程度尚不清楚。
目的：在美国全国范围内调查妇产科住院医师门诊医疗服务点的按支付方分类的流行情况，并比较住院医师和项目主任对支付方分类和整合站点之间医疗质量差异的看法。
设计、地点和参与者：这项全国性调查研究包括截至 2023 年 1 月，美国所有 6060 名妇产科住院医师和 293 名妇产科住院医师培训项目主任。根据项目主任的报告，计算出这种模式在美国妇产科的全国流行率，以描述其在妇产科的比例。比较支付方分类站点的住院医师和项目主任对医疗质量差异的看法。
主要结果和措施：主要衡量标准是美国妇产科住院医师培训项目中按支付方分类的流行情况，由住院医师培训项目主任报告。次要衡量标准是这些门诊医疗环境中住院医师和项目主任对护理质量的看法。在研究开始之前，研究假设是与整合站点相比，在有按支付方分类的门诊站点工作的住院医师和项目主任，在居民和教职员工实践之间感知到的医疗质量差异更大。
结果：共有 251 名住院医师培训项目主任（回复率 85.7%）和 3471 名住院医师（回复率 57.3%）参加了这项研究。住院医师受访者的人口统计学特征反映了全国妇产科住院医师的人口统计学特征，包括种族和民族分布（6[0.2%]美洲印第安人或阿拉斯加原住民；425[13.0%]亚洲人；239[7.3%]黑人或非裔美国人；290[8.9%]西班牙裔、拉丁裔或西班牙语裔；7[0.2%]夏威夷原住民或其他太平洋岛民；2052[62.7%]非西班牙裔白人；49[1.5%]多种族；56[1.7%]其他[任何未列出的种族]；和 137[4.2%]选择不回答）和地理分布（按支付方分类的地区流行情况：东北部 36 个[67.9%]，中西部 35 个[79.5%]，南部 43 个[64.2%]，西部 13 个[59.1%]），其中 2837 名受访者（86.9%）为女性。在项目主任中，有 127 人（68.3%）报告了门诊医疗服务中的按支付方分类。与社区、混合和军事项目相比，大学项目更有可能报告按支付方分类（63 名[74.1%]与 31 名[67.4%]，32 名[62.7%]与 0 名，分别；P=0.04）。与整合项目相比，支付方分类项目的住院医师不太可能报告居民提供的同等或更高质量的护理，而教职员工则认为如此（1662 名[68.7%]与 692 名[81.6%]分别在分类和整合项目中；P<0.001）。
结论和相关性：在这项对住院医师和住院医师培训项目主任的调查研究中，按支付方分类在美国妇产科住院医师培训项目中很普遍，特别是在大学项目中。这些发现为促进住院医师培训项目中更公平的护理提供了结构改革的机会。
