Starfield B, Cassady C, Nanda J, Forrest C B, Berk R
Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland, USA.
J Fam Pract. 1998 Mar;46(3):216-26.
The purpose of this study was to determine the extent to which consumer and provider reports of primary care differ according to particular characteristics of the primary care setting.
A random sample of consumers was surveyed by telephone in a defined geographic area of Washington, DC, to determine their experiences with care provided to a randomly chosen child. The primary care provider of each respondent was sent a parallel survey. Scores were obtained for each of two subdomains in the four cardinal primary care domains (first contact, longitudinality, comprehensiveness, and coordination) and for three related domains (family centeredness, community orientation, and cultural competence). Differences between settings that did or did not impose limitations on autonomy for referrals and between fee-for-service and capitated settings were ascertained.
Both consumers and their providers in settings characterized by high degrees of limitation on physician autonomy or by capitation reported better first-contact accessibility and a greater range of services available than did consumers in settings with low degrees of limitation, or by fee-for-service reimbursements to physicians. Consumers but not providers reported better family centeredness in these settings. Most other differences favored these settings as well, but these were not consistently statistically significant for both providers and consumers in both types of settings.
The quality of primary care services in different settings can be ascertained by using an instrument with demonstrated reliability and convergent validity. Although certain types of settings, in the particular geographic area studied, appear to perform better in several key aspects of the primary care, replication of the study in other areas would be useful judging the performance of the newer types of settings to be superior to more conventional care for general populations.
本研究的目的是确定根据基层医疗服务机构的特定特征，消费者和提供者对基层医疗服务的报告存在多大程度的差异。
在华盛顿特区的一个特定地理区域，通过电话对消费者进行随机抽样调查，以确定他们对随机选择的一名儿童所接受医疗服务的体验。向每位受访者的基层医疗服务提供者发送一份平行调查问卷。在四个主要基层医疗领域（首次接触、连续性、全面性和协调性）的两个子领域以及三个相关领域（以家庭为中心、社区导向和文化能力）中分别获得得分。确定在转诊自主权方面有限制和无限制的机构之间以及按服务收费和按人头计费的机构之间的差异。
与转诊自主权限制程度低或按服务收费报销的机构中的消费者相比，在医生自主权受到高度限制或按人头计费的机构中的消费者及其提供者均报告首次接触的可及性更好且可获得的服务范围更广。在这些机构中，消费者而非提供者报告以家庭为中心的程度更高。大多数其他差异也有利于这些机构，但在这两种类型的机构中，对提供者和消费者而言，这些差异在统计学上并非始终显著。
可以使用具有已证明的可靠性和收敛效度的工具来确定不同机构中基层医疗服务的质量。尽管在研究的特定地理区域，某些类型的机构在基层医疗的几个关键方面似乎表现更好，但在其他地区重复该研究将有助于判断新型机构的表现是否优于针对普通人群的更传统的医疗服务。
