Lynch M
Public Health Research Unit, University of Glasgow.
Br J Gen Pract. 1995 Apr;45(393):205-8.
The target-linked payments introduced by the 1990 general practitioners' contact were intended to reflect a close association between payments and performance in general practice. However, a straightforward direct relationship between service uptake in primary care and financial incentives should not be assumed.
This study set out to examine the relationship between the factors which provide a broad profile of practices and general practitioners' performance in terms of primary childhood immunization targets.
Anonymized data on primary immunization uptake rates in 208 practices in Greater Glasgow Health Board and selected characteristics of the practices and their patient populations were analysed.
Seventy five per cent of the practices in the study qualified for a high-target payment in the last quarter of the 1991-92 financial year, but only 53% managed to do so in all four quarters of the year. Tests of differences between means showed that the provision of child health surveillance, the notional' mortality ratio for each practice's patient population and the percentage of patients attracting deprivation payments were significant differentiating factors among the practices grouped according to immunization target achieved at 1 October 1991--high target, low target and neither. There was no evidence that the target achieved was significantly affected by the activity or clinical staffing levels of the practices--number of patients per general practitioner, number of practice nurses or being single handed. A disproportionate number of practices reaching the high target were located in the more affluent areas, whereas a higher than expected proportion of those which either achieved the low target or missed both targets was located in the more deprived areas. Similar results were obtained when the performance of the practices in achieving the high target over four consecutive quarters was considered.
Practice serving populations living in socially deprived areas and with poorer health were less likely to achieve the high target for childhood immunizations. Evidence of repetition of performance in immunization uptake among the practices leads to concern over increased risk of infectious diseases among children from socially deprived populations who fail to be immunized. This seems to be yet another example of the inverse care law.
1990年全科医生合同引入的目标挂钩支付旨在反映全科医疗中支付与绩效之间的紧密联系。然而，不应假定初级保健服务的利用与经济激励之间存在直接的简单关系。
本研究旨在探讨能全面描述诊所情况的因素与全科医生在儿童初级免疫目标方面的绩效之间的关系。
对大格拉斯哥健康委员会208家诊所的初级免疫接种率的匿名数据以及诊所及其患者群体的选定特征进行了分析。
在1991 - 1992财政年度的最后一个季度，研究中的75%的诊所符合高目标支付条件，但只有53%的诊所在该年度的四个季度都做到了这一点。均值差异检验表明，儿童健康监测的提供情况、每个诊所患者群体的“名义”死亡率以及获得贫困补贴的患者百分比，是根据1991年10月1日实现的免疫目标（高目标、低目标和无目标）分组的诊所之间的显著区分因素。没有证据表明实现的目标受到诊所的活动或临床人员配备水平（每位全科医生的患者数量、执业护士数量或是否单人执业）的显著影响。达到高目标的诊所中，位于较富裕地区的数量不成比例，而那些实现低目标或两个目标都未达到的诊所中，位于较贫困地区的比例高于预期。当考虑诊所连续四个季度实现高目标的表现时，也得到了类似的结果。
为生活在社会贫困地区且健康状况较差的人群提供服务的诊所，实现儿童免疫高目标的可能性较小。诊所免疫接种表现的重复性证据令人担忧，未接种疫苗的社会贫困人群中的儿童感染传染病的风险增加。这似乎又是反向医疗法则的一个例子。
