【社会人文】Pay for Performance(P4P) — 为医生设下的
By SANDEEP JAUHAR, M.D
Published: September 8, 2008
Not long ago, a colleague asked me for help in treating a patient with congestive heart failure who had just been transferred from another hospital.
When I looked over the medical chart, I noticed that the patient, in his early 60s, was receiving an intravenous antibiotic every day. No one seemed to know why. Apparently it had been started in the emergency room at the other hospital because doctors there thought he might have pneumonia.
But he did not appear to have pneumonia or any other infection. He had no fever. His white blood cell count was normal, and he wasn’t coughing up sputum. His chest X-ray did show a vague marking, but that was probably just fluid in the lungs from heart failure.
I ordered the antibiotic stopped — but not in time to prevent the patient from developing a severe diarrheal infection called C. difficile colitis, often caused by antibiotics. He became dehydrated. His temperature spiked to alarming levels. His white blood cell count almost tripled. In the end, with different antibiotics, the infection was brought under control, but not before the patient had spent almost two weeks in the hospital.
我把抗生素从治疗中停掉 — 但不久又不得不重新使用，因为病人因羧状芽孢杆菌感染出现了严重的腹泻，这通常是由抗生素滥用造成的。病人出现了脱水，体温上升到可怕的高度，白细胞计数也几乎升高了3倍。最后，尝试了不同的几种抗生素治疗，感染终于得到控制，但这几乎让病人在医院呆了2周。
The case illustrates a problem all too common in hospitals today: patients receiving antibiotics without solid evidence of an infection. And part of the blame lies with a program meant to improve patient care.
The program is called pay for performance, P4P for short. Employers and insurers, including Medicare, have started about 100 such initiatives across the country. The general intent is to reward doctors for providing better care.
For example, doctors receive bonuses if they prescribe ACE inhibitor drugs to patients with congestive heart failure. Hospitals get bonuses if they administer antibiotics to pneumonia patients in a timely manner.
On the surface, this seems like a good idea: reward doctors and hospitals for quality, not just quantity. But even as it gains momentum, the initiative may be having untoward consequences.
To get an inkling of the potential problems, one simply has to look at another quality-improvement program: surgical report cards. In the early 1990s, report cards were issued on surgeons performing coronary bypasses. The idea was to improve the quality of cardiac surgery by pointing out deficiencies in hospitals and surgeons; those who did not measure up would be forced to improve.
作者:admin@医学,生命科学 2011-06-21 05:11