Shah-Canning D, Alpert J J, Bauchner H
Division of General Pediatrics, Boston City Hospital, Boston University School of Medicine, MA, USA.
Med Care. 1996 Dec;34(12):1171-9. doi: 10.1097/00005650-199612000-00002.
Since World War II, the urban hospital emergency room has been a major source of medical care for inner-city poor families, many of whom receive Medicaid. Given the expensive and episodic nature of emergency room care, there has been renewed interest in enrolling Medicaid recipients into managed care plans to increase access to care and to reduce medical costs. Thus, the primary care physician, in many managed care plans, is expected to give prior approval for emergency room care in nonurgent situations. The goals of managed care may create tension between its requirements and historical patterns of inner-city families seeking care in an emergency room. In 1964, Alpert developed a typology that categorized inner-city families' patterns of seeking medical care in a pediatric emergency department (PED) by describing the relation between regular source of medical care and reliance on this source before the PED visit. In 1976, using the same typology, Alpert and Scherzer updated care-seeking patterns in Boston after the introduction of neighborhood health centers (NHCs) and Medicaid. In 1993, the typology is a method that can be used to assess the impact of managed care on PED utilization by inner-city families. This article compares the 1993 pattern of seeking PED care with that measured in 1964 and 1976.
In 1964, 1976, and 1993 families were interviewed as they sought care in a PED. Families were asked if they had a regular source of care, defined as the place where families take their child most often for either well or sick visits. A judgment was made as to whether or not the PED visit was coordinated with their regular source of care. Coordinated care was defined as having a regular source of care and attempting to contact the source before the PED visit. Uncoordinated care occurred when the family had a regular source and did not attempt contact, or had no regular source.
In 1964, 63% of families reported a regular source of care compared with 89% in 1976 and 95% in 1993. The hospital was reported as the regular source of care by 57% of the respondents in 1964, by 31% in 1976, and 43% in 1993. Community-based sources (physicians and NHCs) were identified as a regular source of care by 43% in 1964, 69% in 1976, and 57% in 1993. In 1964, 55% of the families engaged in an uncoordinated pattern of seeking care compared with 64% in 1976 and 72% in 1993.
Efforts to provide access to care through Medicaid, NHCs, and hospital-based primary care resulted in a greater percentage of families reporting a regular source of care; however, a majority of families continue to exhibit an uncoordinated pattern of seeking care. More families in 1993 did not contact their regular source before seeking care in the PED when compared with 1964 and 1976. For managed care plans to increase access and reduce costs, a shift in PED utilization patterns remains necessary. The primary care system must have the capacity to accommodate these changes and considerable patient education must occur if urgent care is to be provided outside the PED.
自第二次世界大战以来，城市医院急诊室一直是市中心贫困家庭医疗服务的主要来源，其中许多家庭接受医疗补助。鉴于急诊室护理费用高昂且具有突发性，人们重新燃起了将医疗补助领取者纳入管理式医疗计划的兴趣，以增加医疗服务可及性并降低医疗成本。因此，在许多管理式医疗计划中，初级保健医生需要在非紧急情况下对急诊室护理给予事先批准。管理式医疗的目标可能会在其要求与市中心家庭在急诊室寻求护理的历史模式之间造成紧张关系。1964年，阿尔珀特开发了一种类型学，通过描述常规医疗来源与在儿科急诊室（PED）就诊前对该来源的依赖程度之间的关系，对市中心家庭在儿科急诊室寻求医疗护理的模式进行分类。1976年，阿尔珀特和舍尔泽使用相同的类型学，在引入社区健康中心（NHC）和医疗补助后更新了波士顿的就医模式。1993年，这种类型学是一种可用于评估管理式医疗对市中心家庭儿科急诊室利用率影响的方法。本文将1993年儿科急诊室就医模式与1964年和1976年测量的模式进行比较。
在1964年、1976年和1993年，当家庭在儿科急诊室寻求护理时对其进行访谈。询问家庭是否有常规医疗来源，定义为家庭带孩子进行定期健康检查或生病就诊最常去的地方。判断儿科急诊室就诊是否与其常规医疗来源协调。协调护理定义为有常规医疗来源并在儿科急诊室就诊前试图联系该来源。当家庭有常规医疗来源但未尝试联系或没有常规医疗来源时，就会出现不协调护理。
1964年，63%的家庭报告有常规医疗来源，1976年为89%，1993年为95%。1964年，57%的受访者将医院报告为常规医疗来源，1976年为31%，1993年为43%。1964年，43%的社区来源（医生和社区健康中心）被确定为常规医疗来源，1976年为69%，1993年为57%。1964年，55%的家庭采用不协调的就医模式，1976年为64%，1993年为72%。
通过医疗补助、社区健康中心和医院初级保健提供医疗服务的努力，使得报告有常规医疗来源的家庭比例更高；然而，大多数家庭仍然表现出不协调的就医模式。与1964年和1976年相比，1993年更多家庭在儿科急诊室寻求护理前未联系其常规医疗来源。为了使管理式医疗计划增加医疗服务可及性并降低成本，儿科急诊室利用模式的转变仍然是必要的。初级保健系统必须有能力适应这些变化，如果要在儿科急诊室外提供紧急护理，还必须进行大量的患者教育。
