Morrissey J P, Harris R P, Kincade-Norburn J, McLaughlin C, Garrett J M, Jackman A M, Stein J S, Lannon C, Schwartz R J, Patrick D L
Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, USA.
Med Care. 1995 Apr;33(4):315-31.
A randomized, controlled trial was conducted to assess the effects of a financial and office systems intervention to increase preventive care in physicians' offices for patients aged 65 years or older. A total of 1,914 patients from 10 primary-care medical practices in central North Carolina were randomized within practices to an intervention and a usual-care control group. The intervention consisted of full Medicare reimbursement to physicians for preventive care and health promotion packages (thus making these services free for patients), regular prompting of physicians to routinely schedule preventive care visits, a new office system in which nurses carried out many preventive procedures, and a form for charting preventive care. The performance of screening tests dramatically increased in the intervention group relative to control (P < 0.001), but there was evidence of lack of follow-up of abnormal findings by physicians. At the 2-year follow-up, there were minimal differences between intervention and control groups in health-related quality-of-life indicators. Relative to the $294 per patient 3-year cost to Medicare for waivered services, the intervention was reimbursed-cost neutral or slightly cost reducing ($190 over 3 years) for Medicare. It is concluded that adding reimbursement for preventive services to Medicare--even with the office systems changes made in this study--will not by itself lead to effective implementation of preventive services in community medical practices. To enhance patient benefit from preventive services, greater attention needs to be focused on an organized approach to patient follow-up.
开展了一项随机对照试验，以评估财务和办公系统干预措施对增加医生办公室为65岁及以上患者提供预防性护理的效果。北卡罗来纳州中部10家初级保健医疗诊所的1914名患者在诊所内被随机分为干预组和常规护理对照组。干预措施包括向医生全额报销预防性护理和健康促进套餐费用（从而使这些服务对患者免费），定期提醒医生常规安排预防性护理就诊，建立新的办公系统，由护士执行许多预防性程序，以及用于记录预防性护理的表格。与对照组相比，干预组的筛查测试执行情况显著增加（P < 0.001），但有证据表明医生对异常检查结果缺乏后续跟进。在2年随访时，干预组和对照组在健康相关生活质量指标方面差异极小。相对于医疗保险为豁免服务为每位患者支付的3年294美元成本，该干预措施对医疗保险而言是成本中性或略有成本降低（3年节省190美元）。得出的结论是，即使在本研究中对办公系统进行了更改，向医疗保险增加预防性服务报销本身也不会导致社区医疗实践中有效实施预防性服务。为了提高患者从预防性服务中获得的益处，需要更加关注有组织的患者后续跟进方法。
