COSTS VS QUALITY IN DIFFERENT TYPES OF PRIMARY-CARE SETTINGS
COSTS VS QUALITY IN DIFFERENT TYPES OF PRIMARY-CARE SETTINGS
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DOI：
10.1001/jama.272.24.1903
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发表时间：
1994-12-28
影响因子：
120.7
通讯作者：
GERSTENBERGER, A
中科院分区：
文献类型：
--
作者：
STARFIELD, B;POWE, NR;GERSTENBERGER, A
客观。-为了确定资源使用效率和医生提供的护理质量之间的关系，作为国家医疗补助计划中患者的常规护理来源。回顾性护理质量审查的2024门诊医疗记录的135个供应商抽样从系统范围内的医疗补助索赔数据在马里兰州。提供者在三种类型的实践设置（医院门诊，社区卫生中心，医生的办公室）被分层为三个案件混合调整资源使用组（高，中，低）。诊断为糖尿病、高血压、哮喘、良好儿童护理或中耳炎的患者样本是从1988年访问的医疗补助索赔表中确定的。病例组合由门诊护理组的应用控制，这是一种根据发病率负担来描述人群特征的方法。来自当地同行评议组织的护士使用明确的护理质量标准审核了医疗记录，这些标准分为几类：访问障碍的证据，技术质量受损的证据，不适当护理的证据，护理结果和几个通用质量指标，对成人诊断的患者进行了良好的成人护理评估。虽然在护理质量的某些方面，不同类型的设施存在一些系统性差异，（医院诊所的患者存在更多的访问问题，办公室实践中的患者存在更多的技术质量问题），不同类型环境中患者的整体护理质量没有一致的差异，成本效益和护理质量之间没有一致的关系，但是，在21项质量评估类型的比较中，中等成本社区中心的患者得分最高或次高。初级保健中为常见疾病提供的护理质量与提供者产生的费用无关。针对低成本与高成本提供者选择的政策不一定会导致护理质量下降。各州可以通过长期持续监测项目来提高质量和降低成本。中等成本的社区卫生服务中心对患者的护理质量普遍较高，这一发现值得进一步研究。
Objective.-To determine the relationship between efficiency in use of resources and quality of care provided by physicians serving as the usual source of care for patients in a state Medicaid program.Design.-Retrospective quality-of-care review of 2024 outpatient medical records of 135 providers sampled from system-wide Medicaid claims data in Maryland.Subjects.-Providers in three types of practice settings (hospital outpatient clinic, community health center, and physician's office) were stratified into three case mix-adjusted resource use groups (high, medium, and low). A sample of patients with the diagnoses of diabetes, hypertension, asthma, well-child care, or otitis media were identified from Medicaid claims forms from visits during 1988. Case mix was controlled by the application of the ambulatory care groups, a method that characterizes populations according to their burden of morbidity.Main Outcome Measures.-Nurses from the local peer review organization audited medical records using explicit criteria for quality of care in several categories: evidence of impaired access, evidence of compromised technical quality, evidence of inappropriate care, outcome of care, and several generic indicators of quality, Well-adult care was assessed for patients with the adult diagnoses.Results.-Although there were some systematic differences by type of facility in some aspects of quality of care (more access problems for patients in hospital clinics and more technical quality problems for patients in office-based practice), there were no consistent differences in quality of care overall for patients in different types of settings and no consistent relationships between cost-efficiency and quality of care, However, patients in medium-cost community hearth centers had the best or second best scores for most of the 21 comparisons of type of quality assessed.Conclusions. Quality of care provided for common conditions in primary care is not associated with costs generated by providers. Policies directed toward the choice of low-cost vs high-cost providers will not necessarily lead to a deterioration in the quality of care. States can both improve quality and lower costs by consistent monitoring of programs over time. The finding of generally higher quality of care for patients in medium-cost community health centers deserves further study.