Gabriel S E, Amadio P C, Ilstrup D M, Harmsen W S, Huschka T R, Hill J L, Yawn B P
Department of Health Sciences Research, Mayo Clinic and Foundation, Rochester, Minnesota, USA.
J Rheumatol. 2000 Oct;27(10):2412-7.
Uncertainty regarding diagnosis is associated with lower patient satisfaction and can lead to delays in definitive treatment and to inappropriate use of resources. We sought to compare change in diagnosis among orthopedists and non-orthopedists caring for a community based cohort of individuals with incident acute knee injuries.
We conducted a longitudinal investigation of a population based cohort of Olmsted County residents with their first episode of acute knee injury occurring between January 1, 1993, and December 31, 1995. We reviewed the entire (inpatient and outpatient) medical records for these patients and collected extensive clinical data on all diagnoses made (including possible and probable) and the specialty of the attending physician(s) making them. Diagnoses were categorized as: (1) meniscus injury, cruciate injury, or osteochondral fracture; (2) ligament injury, patellar instability, patellar injury; or (3) sprain, strain, injury (unspecified). Diagnostic switches were defined as changes from one diagnostic category to another, or the addition or subtraction of a diagnostic category. We then examined the quality of the documented evidence supporting meniscal, ligamentous, and cruciate diagnoses (at initial evaluation) by comparing the clinical evidence to the recommendations outlined by the American Academy of Orthopaedic Surgeons clinical algorithm on acute knee injury. Analyses were conducted comparing (1) the number of diagnostic switches and (2) the quality of the documented evidence among those cases initially cared for by orthopedists and those cared for by non-orthopedists, using logistic regression analysis adjusting for age, sex, and injury severity. The influence of these variables on costs of care was also examined.
There were 664 patients (361 men and 303 women) in our study population, with an average age of 36.0 years (minimum 17, maximum 87). Of these, 324 were excluded because they only had one clinical encounter for their acute knee injury. Of the remaining 340, 59 (17.4%) were initially cared for by an orthopedist and 211 (62.1%) were cared for by an orthopedist at some time during their care. Diagnostic switches were significantly less frequent in the group who were cared for by orthopedists (55% vs 74%, p < 0.001). This result persisted after adjusting for age, sex, and severity (p = 0.003). The proportion of cases whose diagnoses were supported by evidence was significantly higher among the group whose first attending physician was an orthopedist (63.0% vs 37.6%, p = 0.002). Both change in diagnosis (p < 0.001) and physician specialty (p < 0.001) were statistically significant predictors of costs of care.
Compared to non-orthopedic care, orthopedic care for acute knee injury was associated with fewer changes in diagnosis, and diagnoses made by orthopedists were more likely to be supported by evidence. However, even after adjusting for severity, orthopedic care remained significantly more costly than non-orthopedic care.
诊断的不确定性与患者满意度降低相关，并可能导致确定性治疗的延迟以及资源的不当使用。我们试图比较骨科医生和非骨科医生对一组社区急性膝关节损伤患者进行诊断时的变化情况。
我们对奥尔姆斯特德县居民中1993年1月1日至1995年12月31日首次发生急性膝关节损伤的人群进行了纵向调查。我们查阅了这些患者的全部（住院和门诊）病历，并收集了所有已做出诊断（包括可能和大概的诊断）以及做出诊断的主治医生专业的广泛临床数据。诊断分为：（1）半月板损伤、交叉韧带损伤或骨软骨骨折；（2）韧带损伤、髌骨不稳定、髌骨损伤；或（3）扭伤、拉伤、损伤（未明确）。诊断转换定义为从一个诊断类别到另一个诊断类别，或诊断类别的增加或减少。然后，我们通过将临床证据与美国矫形外科医师学会急性膝关节损伤临床算法中概述的建议进行比较，检查了（初始评估时）支持半月板、韧带和交叉韧带诊断的记录证据的质量。使用逻辑回归分析对年龄、性别和损伤严重程度进行调整，比较（1）诊断转换的数量和（2）最初由骨科医生治疗的病例与由非骨科医生治疗的病例中记录证据的质量。还检查了这些变量对护理成本的影响。
我们的研究人群中有664名患者（361名男性和303名女性），平均年龄为36.0岁（最小17岁，最大87岁）。其中，324人因急性膝关节损伤仅接受了一次临床诊治而被排除。在其余340人中，59人（17.4%）最初由骨科医生治疗，211人（62.1%）在治疗期间的某个时间由骨科医生治疗。在由骨科医生治疗的组中，诊断转换的频率明显较低（55%对74%，p<0.001）。在对年龄、性别和严重程度进行调整后，这一结果仍然存在（p = 0.003）。首次主治医生为骨科医生的组中，诊断有证据支持的病例比例明显更高（63.0%对37.6%，p = 0.002）。诊断变化（p<0.001）和医生专业（p<0.001）都是护理成本的统计学显著预测因素。
与非骨科护理相比，急性膝关节损伤的骨科护理诊断变化较少，骨科医生做出的诊断更有可能得到证据支持。然而，即使在对严重程度进行调整后，骨科护理的成本仍明显高于非骨科护理。
