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【社会人文】Pay for Performance(P4P) — 为医生设下的
By SANDEEP JAUHAR, M.D
Published: September 8, 2008
绩效给付，医生的“陷阱”
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.
不久以前，我的同事请我帮忙看一位刚从其它医院转来的患有充血性心力衰竭的病人。
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.
在翻阅治疗记录时，我注意到，这位50多岁的病人每天都在接受静脉注射抗生素治疗，似乎没有人知道为什么要这样做。很明显，病人是在别的医院急诊室开始使用的抗生素，因为那儿的医生认为他可能有肺炎。
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.
病人看起来没有肺炎或者任何其它感染的迹象，他没有发热，白细胞计数正常，也没有咳痰。病人的胸部X线确实有些模糊阴影，但那可能是由于心力衰竭导致的肺水肿的征象。
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.
这个案例反映了当今医院普遍存在的问题：在没有确切的感染证据的情况下，轻易给病人使用抗生素。这一现象至少应部分归咎于一项试图改善医疗服务的计划。
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.
这一计划被称作“绩效给付”，简称“P4P”。雇主和保险公司，包括联邦医疗保险，已经在全美100家医院启动了这项计划，它的意图是对提供良好医疗服务的医生进行奖励。
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.
例如，医生如果给充血性心衰的患者使用血管紧张素转换酶抑制剂，就会得到奖金；医院如果能及时给肺炎患者使用抗生素，也会得到奖金。
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.
表面上，这象是个好主意：根据医疗服务质量，而不再仅仅根据数量，奖励医生和医院。但是，甚至从这个项目推进伊始，就带来了不良后果。
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.
为了更好地说明这些潜在的问题，不妨简单回顾一下另外一项医疗质量推进计划：手术报告卡制度。20世纪90年代初期，报告卡制度被应用到冠状动脉搭桥手术，是想通过指出医院和医生存在的不足，提高心脏手术的质量：不符合质量要求的手术者将被强制要求改进。
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作者:admin@医学,生命科学 2011-06-21 05:11
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