Pearson S D, Lee T H, Lindsey E, Hawkins T, Cook E F, Goldman L
Department of Ambulatory Care and Prevention, Harvard Community Health Plan, Boston, MA.
Health Serv Res. 1994 Apr;29(1):59-74.
We evaluate the impact of membership in a staff-model health maintenance organization (HMO) on hospital admission rates for patients presenting to an emergency department with acute chest pain.
Primary prospective data were gathered from all 3,006 patients presenting with a chief complaint of chest pain to the emergency department (ED) of a university teaching hospital from October 1987 to November 1989.
Prospective cohort analysis used clinical data to stratify patients into groups at high (> or = 25%), medium (8-24%), and low risk (< or = 7%) of acute myocardial infarction (AMI). Insurance status was determined as either HMO, Medicare, commercial, Medicaid, or self-pay. Triage decisions were recorded, and patient outcomes of AMI and other final diagnoses were determined for all patients.
Clinical data were recorded by the physicians in the ED as part of a detailed protocol. Insurance data were recorded separately by the ED staff as part of the hospital administrative database. Patient outcomes were recorded daily by research nurses for hospitalized patients; for patients who were discharged from the ED, telephone or physician follow-up was accomplished within seven days after discharge.
HMO patients were more likely to be admitted to the hospital than patients in other insurance groups in both the medium- and low-risk patient categories. Within the low-risk category, after controlling for clinical differences in a multiple logistic model, HMO membership retained an independent positive association with hospital admission compared to all other insurance groups except Medicaid.
For patients with acute chest pain who were at medium and low risk of acute myocardial infarction, HMO membership was associated with higher rates of hospital admission. These findings suggest that organizational factors beyond financial incentives may exercise an important influence on hospitalization rates for HMO patients.
我们评估加入员工型健康维护组织（HMO）对因急性胸痛到急诊科就诊的患者住院率的影响。
主要前瞻性数据收集自1987年10月至1989年11月到一所大学教学医院急诊科就诊、主诉胸痛的所有3006例患者。
前瞻性队列分析利用临床数据将患者分为急性心肌梗死（AMI）高风险（≥25%）、中风险（8 - 24%）和低风险（≤7%）组。保险状态确定为HMO、医疗保险、商业保险、医疗补助或自费。记录分诊决策，并确定所有患者的AMI及其他最终诊断的患者结局。
急诊科医生按照详细方案记录临床数据。急诊科工作人员将保险数据作为医院管理数据库的一部分单独记录。研究护士每天记录住院患者的患者结局；对于从急诊科出院的患者，在出院后7天内通过电话或医生随访完成。
在中风险和低风险患者类别中，HMO患者比其他保险组的患者更有可能住院。在低风险类别中，在多因素逻辑模型中控制临床差异后，与除医疗补助外的所有其他保险组相比，HMO成员资格与住院仍保持独立的正相关。
对于急性心肌梗死中低风险的急性胸痛患者，HMO成员资格与较高的住院率相关。这些发现表明，除经济激励因素外的组织因素可能对HMO患者的住院率产生重要影响。
