Starfield B, Powe N R, Weiner J R, Stuart M, Steinwachs D, Scholle S H, Gerstenberger A
Department of Health Policy and Management, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, MD 21205-1996.
JAMA. 1994 Dec 28;272(24):1903-8.
To determine the relationship between efficiency in use of resources and quality of care provided by physicians serving as the usual source of care for patients in a state Medicaid program.
Retrospective quality-of-care review of 2024 outpatient medical records of 135 providers sampled from system-wide Medicaid claims data in Maryland.
Providers in three types of practice settings (hospital outpatient clinic, community health center, and physician's office) were stratified into three case mix-adjusted resource use groups (high, medium, and low). A sample of patients with the diagnoses of diabetes, hypertension, asthma, well-child care, or otitis media were identified from Medicaid claims forms from visits during 1988. Case mix was controlled by the application of the ambulatory care groups, a method that characterizes populations according to their burden of morbidity.
Nurses from the local peer review organization audited medical records using explicit criteria for quality of care in several categories: evidence of impaired access, evidence of compromised technical quality, evidence of inappropriate care, outcome of care, and several generic indicators of quality. Well-adult care was assessed for patients with the adult diagnoses.
Although there were some systematic differences by type of facility in some aspects of quality of care (more access problems for patients in hospital clinics and more technical quality problems for patients in office-based practice), there were no consistent differences in quality of care overall for patients in different types of settings and no consistent relationships between cost-efficiency and quality of care. However, patients in medium-cost community health centers had the best or second best scores for most of the 21 comparisons of type of quality assessed.
Quality of care provided for common conditions in primary care is not associated with costs generated by providers. Policies directed toward the choice of low-cost vs high-cost providers will not necessarily lead to a deterioration in the quality of care. States can both improve quality and lower costs by consistent monitoring of programs over time. The finding of generally higher quality of care for patients in medium-cost community health centers deserves further study.
确定在一个州医疗补助计划中，为患者提供常规医疗服务的医生在资源利用效率与所提供医疗服务质量之间的关系。
对从马里兰州全系统医疗补助索赔数据中抽取的135名医疗服务提供者的2024份门诊病历进行回顾性医疗质量审查。
三种执业环境（医院门诊诊所、社区健康中心和医生办公室）中的医疗服务提供者被分层为三个病例组合调整后的资源利用组（高、中、低）。从1988年就诊的医疗补助索赔表中识别出诊断为糖尿病、高血压、哮喘、儿童健康护理或中耳炎的患者样本。病例组合通过应用门诊护理组进行控制，该方法根据人群的发病负担对人群进行特征描述。
当地同行评审组织的护士使用明确的护理质量标准对病历进行审核，这些标准涉及几个类别：就医不便的证据、技术质量受损的证据、不适当护理的证据、护理结果以及几个通用的质量指标。对诊断为成人疾病的患者进行健康成人护理评估。
尽管在护理质量的某些方面，不同类型机构存在一些系统性差异（医院诊所的患者就医问题更多，基于办公室执业的患者技术质量问题更多），但不同类型环境中的患者在总体护理质量上没有一致的差异，成本效益与护理质量之间也没有一致的关系。然而，在评估的21项质量类型比较中，大多数情况下，中等成本社区健康中心的患者得分最佳或次佳。
初级保健中常见病症的护理质量与医疗服务提供者产生的成本无关。针对选择低成本或高成本医疗服务提供者的政策不一定会导致护理质量下降。随着时间的推移，通过持续监测项目，各州可以在提高质量的同时降低成本。中等成本社区健康中心的患者护理质量普遍较高这一发现值得进一步研究。
