Resolving the gatekeeper conundrum - What patients value in primary care and referrals to specialists
Resolving the gatekeeper conundrum - What patients value in primary care and referrals to specialists
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DOI：
10.1001/jama.282.3.261
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发表时间：
1999-07-21
影响因子：
120.7
通讯作者：
Uratsu, C
中科院分区：
文献类型：
--
作者：
Grumbach, K;Selby, JV;Uratsu, C
背景 关于患者如何看待初级保健医生在管理式医疗体系中作为“把关人”的角色，现有的数据很少。
目的 确定患者在多大程度上重视其初级保健医生作为首诊医疗服务提供者和转诊协调者的角色，患者是否认为他们的初级保健医生阻碍了他们看专科医生，以及在获得专科医生服务方面存在的问题是否与患者对其初级保健医生的信任和信心降低有关。
设计、环境和患者 1997年秋季向加利福尼亚州10个大型医生团体所服务的12707名参加管理式医疗计划的成年患者邮寄了横断面调查问卷。符合条件的患者回复率为71%。共有7718名患者（平均年龄66.7岁；32%为女性）符合分析条件。
主要观察指标 调查问卷的项目涉及3个主要主题：（1）患者对其初级保健医生首诊和协调角色的态度；（2）患者对其初级保健医生的评价（信任度、信心以及满意度）；（3）患者对专科转诊障碍的看法。将转诊障碍作为患者对其医生评价的预测因素进行分析。
结果 几乎所有患者都重视初级保健医生作为首诊医疗服务来源（94%）和转诊协调者（89%）的角色。根据具体的医疗问题，75% - 91%的患者更愿意首先向他们的初级保健医生而不是专科医生寻求医疗服务。23%的患者报告说他们的初级保健医生或医疗团体干扰了他们看专科医生的能力。在获得转诊方面有困难的患者更有可能报告对其初级保健医生信任度低（调整后的优势比[OR]，2.7；95%置信区间[CI]，2.1 - 3.5）、信心低（OR，2.2；95% CI，1.6 - 2.9）以及满意度低（OR，3.3；95% CI，2.6 - 4.2）。
结论 患者重视初级保健医生的首诊和协调角色。然而，强调初级保健医生作为把关人阻碍获得专科医生服务的管理式医疗政策会削弱患者对其初级保健医生的信任和信心。
Context Few data are available regarding how patients view the role of primary care physicians as "gatekeepers" in managed care systems.Objective To determine the extent to which patients value the role of their primary care physicians as first-contact care providers and coordinators of referrals, whether patients perceive that their primary care physicians impede access to specialists, and whether problems in gaining access to specialists are associated with a reduction in patients' trust and confidence in their primary care physicians.Design, Setting, and Patients Cross-sectional survey mailed in the fall of 1997 to 12 707 adult patients who were members of managed care plans and received care from 10 large physician groups in California. The response rate among eligible patients was 71%. A total of 7718 patients (mean age, 66.7 years; 32% female) were eligible for analysis.Main Outcome Measures Questionnaire items addressed 3 main topics: (1) patient attitudes toward the first-contact and coordinating role of their primary care physicians, (2) patients' ratings of their primary care physicians (trust and confidence in and satisfaction with), and (3) patient perceptions of barriers to specialty referrals. Referral barriers were analyzed as predictors of patients' ratings of their physicians.Results Almost all patients valued the role of a primary care physician as a source of first-contact care (94%) and coordinator of referrals (89%). Depending on the specific medical problem, 75% to 91% of patients preferred to seek care initially from their primary care physicians rather than specialists. Twenty-three percent reported that their primary care physicians or medical groups interfered with their ability to see specialists. Patients who had difficulty obtaining referrals were more likely to report low trust (adjusted odds ratio [OR], 2.7; 95% confidence interval [CI], 2.1-3.5), low confidence (OR, 2.2; 95% CI, 1.6-2.9), and low satisfaction (OR, 3.3; 95% CI, 2.6-4.2) with their primary care physicians.Conclusions Patients value the first-contact and coordinating role of primary care physicians. However, managed care policies that emphasize primary care physicians as gatekeepers impeding access to specialists undermine patients' trust and confidence in their primary care physicians.