Clancy C M, Franks P
Centers for Primary Care Research and Outcomes and Effectiveness Research, Agency for Health Care Policy and Research, Rockville, MD, USA.
J Fam Pract. 1997 Dec;45(6):500-8.
Appropriate utilization of primary and specialty care has stimulated substantial debate, but the portion of the discussion focused on policies that restrict or discourage direct access to specialists has been largely uninformed by empirical analysis. Using data from the National Ambulatory Care Survey (1985 to 1992 surveys), we examined the associations of patient and physician demographics and health maintenance organization (HMO) insurance status with the utilization of primary compared with specialty care.
Office visits for adult patients seen by primary care physicians and specialists were analyzed for: (1) patient-initiated utilization of specialists (patient self-referral) compared with that of primary care physicians; and (2) utilization of specialists compared with that of primary care physicians, stratified by HMO insurance status.
After multivariate adjustment, patient self-referral was less likely among black patients (adjusted odds ratio [AOR] = 0.67; 95% confidence interval [CI] = 0.59 to 0.76), self-pay (AOR = 0.81; 95% CI = 0.74 to 0.88), or patients with Medicaid (AOR = 0.51; 95% CI = 0.43 to 0.61). The proportion of non-HMO patients seeing specialists remained stable (44.9%). For HMO patients, the proportion of total visits made to specialists increased from 27.6% in 1985 to 41.3% in 1991, then dropped to 33.2% in 1992. Disparities in utilization of specialists by women, blacks, and patients with Medicaid observed among non-HMO patients were not found in the HMO population. Specialists were more likely to see HMO patients for follow-up of a known problem, whereas non-HMO patients were more likely to have specialist follow-up visits for new problems.
The results suggest greater utilization of specialists by male, white, and privately insured patients. The findings may partially account for disparities in specialty procedure use, and suggest that HMO insurance may reduce some of these disparities. The less frequent and more selective use of specialists among HMO patients suggests an evolving role for specialists in managed care.
初级保健和专科保健的合理利用引发了大量争论，但讨论中关于限制或不鼓励直接就诊于专科医生的政策部分，很大程度上缺乏实证分析依据。利用国家门诊医疗调查（1985年至1992年的调查）的数据，我们研究了患者和医生的人口统计学特征以及健康维护组织（HMO）保险状况与初级保健和专科保健利用之间的关联。
分析了初级保健医生和专科医生为成年患者进行的门诊就诊情况，包括：（1）患者主动就诊于专科医生（患者自我转诊）与就诊于初级保健医生的情况比较；（2）按HMO保险状况分层，比较专科医生和初级保健医生的就诊情况。
多变量调整后，黑人患者（调整后的优势比[AOR]=0.67；95%置信区间[CI]=0.59至0.76）、自费患者（AOR=0.81；95%CI=0.74至0.88）或医疗补助患者（AOR=0.51；95%CI=0.43至0.61）自我转诊的可能性较小。非HMO患者就诊于专科医生的比例保持稳定（44.9%）。对于HMO患者，就诊于专科医生的总就诊比例从1985年的27.6%增至1991年的41.3%，然后在1992年降至33.2%。在非HMO患者中观察到的女性、黑人及医疗补助患者在专科医生就诊方面的差异，在HMO人群中未发现。专科医生更有可能为已知问题的随访诊治HMO患者，而非HMO患者更有可能因新问题接受专科医生的随访就诊。
结果表明男性、白人和有私人保险的患者更多地利用专科医生。这些发现可能部分解释了专科手术使用方面的差异，并表明HMO保险可能会减少其中一些差异。HMO患者对专科医生使用频率较低且更具选择性，这表明专科医生在管理式医疗中的角色在不断演变。
