Greenfield S, Rogers W, Mangotich M, Carney M F, Tarlov A R
Health Institute, New England Medical Center, Boston, MA 02111, USA.
JAMA. 1995 Nov 8;274(18):1436-44.
To compare the outcomes of patients with hypertension and non-insulin-dependent diabetes mellitus (NIDDM) who were cared for in three different systems of care and by generalist and subspecialist physicians.
An observational study with follow-up at three periods: (1) a 2-year study of 532 patients with hypertension and 170 patients with NIDDM who had entrance and exit histories, physical examinations, and laboratory tests; (2) a 4-year follow-up of 1044 patients with hypertension and 317 patients with NIDDM based on patient-reported functional status; and (3) 7-year mortality for 1296 patients with hypertension and 424 patients with NIDDM.
Patients sampled from health maintenance organizations, large multispecialty groups, and solo or single-specialty group practices in Boston, Mass, Los Angeles, Calif, and Chicago, Ill. Patients were designated as belonging to one of three systems of care: fee for service; prepaid patients in solo or small single-specialty groups or in large multispecialty group practices, referred to as independent practice associations; and staff-model health maintenance organizations. The principal providers were family practitioners, general internists, cardiologists, or endocrinologists.
Physiological, functional, and mortality. For hypertension, we measured blood pressure and stroke incidence. For NIDDM, we measured blood pressure, glycosylated hemoglobin level, visual function, vibration sense, ulcers and infections in the feet, and albumin excretion rate. Functional outcomes were assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Mortality was assessed for the 7 years following the entrance examination.
We found no evidence that any one system of care or physician specialty achieved consistently better 2-year or 4-year outcomes than others for patients with NIDDM or hypertension. Endocrinologists appeared to achieve better foot-ulcer and infection outcomes for patients with NIDDM, particularly when compared with family practitioners. However, no other specialist differences were found in any individual measures for either condition. Moreover, no adjusted mortality differences among systems or among physicians specialties were observed in the 7-year follow-up period.
No meaningful differences were found in the mean health outcomes for patients with hypertension or NIDDM, whether they were treated by different care systems or by different physician specialists. Although prepaid medicine relies more heavily on generalist physicians than does fee for service, there is no evidence from these analyses that the quality of care of moderately ill patients with these two common disease was adversely affected. These findings must be viewed in light of the historically higher costs of fee-for-service medicine and of subspecialty physician practice.
比较在三种不同医疗体系中，由全科医生和专科医生护理的高血压患者及非胰岛素依赖型糖尿病（NIDDM）患者的治疗结果。
一项观察性研究，分三个阶段进行随访：（1）对532例高血压患者和170例NIDDM患者进行为期2年的研究，记录其入院和出院病史、体格检查及实验室检查结果；（2）基于患者报告的功能状态，对1044例高血压患者和317例NIDDM患者进行为期4年的随访；（3）对1296例高血压患者和424例NIDDM患者进行7年死亡率随访。
从马萨诸塞州波士顿、加利福尼亚州洛杉矶和伊利诺伊州芝加哥的健康维护组织、大型多专科医疗集团以及单人或单专科医疗诊所中抽取患者。患者被指定属于三种医疗体系之一：按服务收费；独立执业协会，即单人或小型单专科医疗集团或大型多专科医疗集团中的预付费患者；以及员工型健康维护组织。主要医疗服务提供者为家庭医生、普通内科医生、心脏病专家或内分泌专家。
生理指标、功能指标和死亡率。对于高血压，测量血压和中风发病率。对于NIDDM，测量血压、糖化血红蛋白水平、视觉功能、振动觉、足部溃疡和感染情况以及白蛋白排泄率。使用医疗结局研究36项简短健康调查（SF - 36）评估功能结局。在入院检查后的7年里评估死亡率。
我们没有发现证据表明，对于NIDDM患者或高血压患者，任何一种医疗体系或医生专科在2年或4年的治疗结果上始终优于其他体系或专科。内分泌专家似乎在NIDDM患者的足部溃疡和感染治疗方面取得了更好的效果，特别是与家庭医生相比。然而，在这两种疾病的任何单项指标中，未发现其他专科之间存在差异。此外，在7年的随访期内，未观察到不同医疗体系或医生专科之间经调整后的死亡率差异。
无论是由不同的医疗体系还是不同的医生专科进行治疗，高血压患者或NIDDM患者的平均健康结局均未发现有意义的差异。尽管预付费医疗比按服务收费更依赖全科医生，但这些分析没有证据表明这两种常见疾病的中度患者的医疗质量受到了不利影响。鉴于按服务收费医疗和专科医生执业在历史上成本更高，必须从这一角度看待这些发现。
