SPECIALTY EFFECT ON PRIMARY CARE PRACTICE IN AN HMO

先前的研究表明，在提供初级保健的医生中， 专业培训可能对实习方式、资源产生显著影响 使用率和护理成本。专科内科医生似乎使用 比普通内科医生更多的医疗资源，而家庭医生 即使在对患者的差异进行调整后，也可能会使用更少的药物 人口。然而，到目前为止的研究还没有清楚地表明这些 在共同的实践环境中，差异仍然存在，也不是 评估一段时间内的总资源利用率或护理成本 病人的群体。 这项前瞻性研究将使用Kaiser的自动化数据系统 北加州永久医疗保健计划(KPMCP)审查 一年内资源利用率和总成本的差异 (1994年7月至1995年6月30日L)患者(年龄35岁和 三组初级保健医生(家庭医生、 普通内科医生和专科内科医生)。它将在以下时间进行 六个毕马威会计师事务所的设施，病人通常被分配到其中两个 三个专科，不考虑他们的疾病或抱怨。 利用措施包括：住院护理、门诊(主要 护理、专科医学和非内科转诊)、急诊 房间用途、实验室、药房、放射学、门诊外科和办公室 程序。每个元素的成本也是可用的。病例组合 专科之间的差异将通过简短的病历来衡量 对来自每个医疗中心的1000名患者的样本进行审查。这个 门诊护理小组(ACG)病例混合系统将适用于所有 前两年发生的诊断。疾病的严重程度将 被评估为五种关键的慢性病。护理质量措施 包括：使用最近发表的报告评估护理的适当性 糖尿病、高血压、哮喘、抑郁症患者指南 和腰背痛；通过成员的数据评估预防实践 在1993年年中由近20,000名成员完成的健康调查；以及 结果(可避免住院和急诊室就诊)。 一个由国家初级保健专家组成的咨询委员会 受聘为病例组合调整决策提供意见， 护理质量比较的评估，以及以下方面的影响 关于国家初级保健政策的调查结果。

Previous studies suggest that among physicians who provide primary care, specialty training may have a marked impact on practice style, resource utilization and the costs of care. Subspecialty internists appear to use more medical resources than general internists, while family practitioners may use somewhat fewer, even after adjusting for differences in patient populations. However, studies to date have not clearly shown that these differences persist in a common practice environment, nor have they assessed total resource utilization or costs of care over time in populations of patients. This prospective study will use the automated data systems of the Kaiser Permanente Medical Care Program (KPMCP) of Northern California to examine differences in resource utilization and total costs during a one-year period (July l, 1994 - June 30, 1995) for patients (age 35 years and older) of three groups of primary care physicians (family practitioners, general internists, and subspecialty internists). It will be conducted in six KPMCP facilities where patients are routinely assigned to two of the three specialties without respect to their illnesses or complaints. Utilization measures include: inpatient care, outpatient visits (primary care, subspecialty medicine and noninternal medicine referrals), emergency room use, laboratory, pharmacy, radiology, outpatient surgery, and office procedures. Costs of each element are also available. Case-mix differences between specialties will be measured by brief medical record review in samples of 1,000 patients from each medical center. The Ambulatory Care Group (ACG) Case-mix System will be applied to all diagnoses occurring during the previous two years. Disease severity will be assessed for five key chronic conditions. Quality of care measures include: assessment of appropriateness of care using recently published guidelines for patients with diabetes, hypertension, asthma, depression and low back pain; prevention practices assessed with data from a Member Health Survey completed by nearly 20,000 members in mid-1993; and medical outcomes (avoidable hospitalizations and emergency room visits). An advisory committee of national experts on primary care has been recruited to provide input into decisions on case-mix adjustment, assessment of quality of care comparisons, and the implications of findings for a national policy on primary care.