Physician response to patient insurance status in ambulatory care clinical decision-making - Implications for quality of care
Physician response to patient insurance status in ambulatory care clinical decision-making - Implications for quality of care
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DOI：
10.1097/00005650-199608000-00006
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发表时间：
1996-08-01
期刊：
影响因子：
3
通讯作者：
Blumenthal, D
中科院分区：
文献类型：
--
作者：
Mort, EA;Edwards, JN;Blumenthal, D
目标。一般来说，没有健康保险的个人获得的医疗服务较少，并且比有保险的患者更有可能经历不良结果。本研究的主要目标是研究医生的临床建议对于投保和未投保患者是否有所不同，这意味着医生的护理选择可能会调节医疗保健使用中与保险相关的差异。方法。作者设计了描述初级保健医生在门诊环境中遇到的常规决策的临床场景。场景设计包括自由裁量、非自由裁量、预防和诊断/治疗服务。患者的保险状况被指示为所考虑的服务的已投保或未投保。作为美国医学会 1992 年社会经济监测系统调查的一部分，我们向具有全国代表性的初级保健医生样本 (n = 1182) 提交了各种情景。医生被随机分配接受八种情况，其中患者要么有保险，要么没有保险。对于每种情况，医生被要求指出他们会推荐给定服务的患者的百分比。结果。在控制与无反应相关的变量后，我们发现，向有保险患者提供场景的医生推荐为 72% 的患者提供服务，而向未参保患者提供场景的医生向 67% 的患者推荐相同的服务 (P < 0.001)。与未参保患者相比，医生更频繁地向参保患者推荐酌情服务（50% 对比 42%；P < 0.001）和非酌情服务（93% 对比 91%；P < 0.05）。结论。在自我报告中，与未参保的患者相比，医生更有可能向参保患者推荐服务，当服务是可自由裁量时更是如此。这提供了证据，表明医生的建议可能是医疗保健服务使用中与保险相关的变化的重要调节因素。被保险人较高的使用率并不总是反映较高的护理质量，特别是当服务本质上是自由裁量的时候。
OBJECTIVES. Individuals without health insurance in general receive fewer health services and are more likely than insured patients to experience poor outcomes. The main goal of this research was to study whether physicians' clinical recommendations vary for insured and uninsured patients, implying that physicians' choices of care may mediate insurance-related differences in health care use.METHODS. The authors designed clinical scenarios that describe routine decisions encountered by primary care physicians in ambulatory settings. Scenarios were designed to include discretionary, nondiscretionary, preventive, and diagnostic/therapeutic services. Insurance status of patients was indicated as either insured or uninsured for the service under consideration. Scenarios were presented to a nationally representative sample of primary care physicians (n = 1182) as part of the American Medical Association 1992 Socioeconomic Monitoring System Survey. Physicians were assigned randomly to receive eight scenarios in which patients were either insured or uninsured. For each scenario, physicians were asked to indicate the percentage of patients for whom they would recommend a given service.RESULTS. After controlling for variables associated with nonresponse, we found that physicians who were presented scenarios with insured patients recommended services for 72% of patients, and physicians who were presented scenarios with uninsured patients recommended the same services for 67% of patients (P < 0.001). Physicians recommended both discretionary services (50% versus 42%; P < 0.001) and nondiscretionary services more often for insured than uninsured patients (93% versus 91%; P < 0.05).CONCLUSIONS. In self-reports, physicians are more likely to recommend services for insured than for uninsured patients, and more so when services are discretionary. This provides evidence that physicians' recommendations may be important mediators of insurance-related variation in the use of health-care services. Higher rates of use among the insured may not always reflect higher quality of care, particularly when the service is discretionary in nature.