Télécharger le rapport (152 p.) - KCE

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108 Urgences KCE reports vol. 19B Publication Data Selby et al NEJM-1996- USA. MESH-terms Objective Planning Conclusion Material/Methods Results / Comments Comments/Discussion Co-payment and emergencyuse.(copa). Effect of a copayment on the use of ED in a HMO. Randomised and controlled prospective trial. A co-payment for the use of a Ed was associated with a decline of about 15% in the use of ED, mostly among inappropriate users. After adjustment for social parameters this study confirms that the selective use of small copayments can safely reduce ED use among people through employers healthinsuredred. Comparisons of ED use one yr before and after the institution of a co-payment. Target is the copa-group(25-35 usd) of a HMO of 20 computer companies.(who already paid 5- 10 usd for outpatient use.) 2 control grps: Random sampling in general population grp, stratified according to age, sex, area, use of ED. Random sampling in a contgrp of similar computer companies that didnÊt institute copa. Same stratification as ctrl 1 group. 4 categories of care(urgent, ED, paediatric and adult offices) Use of ED was linked to the severity of the presenting symptoms ( very urgent, urgent, less urgent, not urgent). Poison regression model. Logistic regression model. The matching of different variables shows that: The socioeconomic status was the same between copagrp.and controlgrp. 2 group, but both higher than crtl.1 grp. Lesser use of ED in copa-grp than in controlgrp 1 and 2,but smaller in 2. Residents of poor neighbourhoods of all grps had 22 % more visits to ED. Decline in visits in 1993 was 15 % greater in the copa-grp than in either ctrlgrp.(p< 0,001) after adjustment. The use of urgent care and office visits were higher in ctrlgrp 1,especially for paediatric visits. For visits involving less severe diagnoses the declines were greater in the copagrp. Than in the ctrlgrp. The always a emergency visits remains stable in the 3 grps. The amount of co-payment had no effect on the change of use. Hospital admissions - A co-payment of 25-35 usd for use of ED led to a 15% reduction with no increase in use of outpa.services. - Copa reduces ED use more for often not an emergency". Like in OÊGrady study the reduction reduced especially the lesser appropriate visits. - The day(triage) and night(no triage) differential for the reduction of visits dealing with often not an emergency was larger at night. This shows indirectly that a triage has an effect. - Other studies( Lohr et al..1986) shows that large co-payments reduce appropriate preventive services and screening mammography. This study could not show an adverse effect. - A greater impact on lower-income socialgrps has been demonstrated in the use of ED at a base line.
KCE reports vol. 19B Urgences 109 OÊGrady K.F. et al. NEJM-Aug. 22-1985 vol.313-nr.8. USA- California. Impact of cost-sharing on ED-use. Costsharing(cosha) and ED-use. Effect of insurance coverage on the use of ED. Data from a national trial of cosha in healthinsurance. Randomised.(
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