The implications of regional variations in medicare spending. Part 1: The content, quality, and accessibility of care
The implications of regional variations in medicare spending. Part 1: The content, quality, and accessibility of care
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DOI：
10.7326/0003-4819-138-4-200302180-00006
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发表时间：
2003-02-18
影响因子：
39.2
通讯作者：
Pinder, EL
中科院分区：
文献类型：
--
作者：
Fisher, ES;Wennberg, DE;Pinder, EL
背景资料：医疗保险支出的地区差异对健康的影响尚不清楚。目的：确定医疗保险支出较高的地区是否提供更好的护理。设计：队列研究。设置：医疗保险受益人的国家研究。患者：1993年至1995年间因髋部骨折住院的患者（n = 614 503），结直肠癌（n = 195 429），或急性心肌梗死（n = 159 393）和代表性样本（n = 18 190）来自Medicare当前受益人调查（1992-1995）.曝光测量：临终支出反映了医疗保险支出的地区差异，与疾病的地区差异无关。因此，每个队列成员暴露于不同水平的支出是由他或她的医院转诊居住地区的临终支出水平定义的（n = 306）。护理内容（例如，接受服务的频率和类型）、护理质量（例如，急性心肌梗死后使用阿司匹林、流感免疫接种）和获得护理结果：在不同支出水平的地区，队列成员的平均基线健康状况相似，但高支出地区的患者接受了约60%的护理。增加的利用率解释为更频繁的医生访问，特别是在住院设置（住院患者就诊率最高与最低五分位数医院转诊地区的比率为2.13 [95% CI，2.12至2.14]，新住院患者就诊率为2.36 [CI，2.33至2.39]），更频繁的检查和轻微的（但不是主要的）程序，增加了专家和医院的使用（住院日最高与最低五分位数的比率为1.52 [CI，1.50至1.54]，重症监护室日为1.55 [CI，1.50至1.60]）。在大多数措施上，高支出地区的护理质量并没有更好，在几项预防性护理措施上更差。在高消费地区获得医疗保健也没有更好或更差。结论：医疗保险支出的区域差异在很大程度上解释了在高消费地区观察到的更多的住院病人为基础的和以专家为导向的实践模式。医疗质量和获得医疗服务的机会似乎都没有更好的医疗保险参保人在高消费地区。
Background: The health implications of regional differences in Medicare spending are unknown.Objective: To determine whether regions with higher Medicare spending provide better care.Design: Cohort study.Setting: National study of Medicare beneficiaries.Patients: Patients hospitalized between 1993 and 1995 for hip fracture (n = 614 503), colorectal cancer (n = 195 429), or acute myocardial infarction (n = 159 393) and a representative sample (n = 18 190) drawn from the Medicare Current Beneficiary Survey (1992-1995).Exposure Measurement: End-of-life spending reflects the component of regional variation in Medicare spending that is unrelated to regional differences in illness. Each cohort member's exposure to different levels of spending was therefore defined by the level of end-of-life spending in his or her hospital referral region of residence (n = 306).Outcome Measurements: Content of care (for example, frequency and type of services received), quality of care (for example, use of aspirin after acute myocardial infarction, influenza immunization), and access to care (for example, having a usual source of care).Results: Average baseline health status of cohort members was similar across regions of differing spending levels, but patients in higher-spending regions received approximately 60% more care. The increased utilization was explained by more frequent physician visits, especially in the inpatient setting (rate ratios in the highest vs. the lowest quintile of hospital referral regions were 2.13 [95% CI, 2.12 to 2.14] for inpatient visits and 2.36 [CI, 2.33 to 2.39] for new inpatient consultations), more frequent tests and minor (but not major) procedures, and increased use of specialists and hospitals (rate ratio in the highest vs. the lowest quintile was 1.52 [CI, 1.50 to 1.54] for inpatient days and 1.55 [CI, 1.50 to 1.60] for intensive care unit days). Quality of care in higher-spending regions was no better on most measures and was worse for several preventive care measures. Access to care in higher-spending regions was also no better or worse.Conclusions: Regional differences in Medicare spending are largely explained by the more inpatient-based and specialist-oriented pattern of practice observed in high-spending regions. Neither quality of care nor access to care appear to be better for Medicare enrollees in higher-spending regions.