Brown L J, Barnett J R
Lipid and Diabetes Research Group, Hagley, Christchurch Hospital, New Zealand.
Soc Sci Med. 1992 Nov;35(9):1157-70. doi: 10.1016/0277-9536(92)90228-i.
This paper undertakes both a macro- and micro-scale analysis of the influences exerted by the health care system on patterns of hospitalization. The health disorder of diabetes mellitus is used as the case study and the analyses are based on New Zealand data sets. The article first examines the extent to which both the supply and organization of primary and secondary health care affect rates of hospitalization. The macro-scale analysis investigates the applicability of Roemer's Law to regional variations in diabetes hospitalization. The organizational control of hospital utilization via doctor gatekeeping functions and interaction between health services are then examined at the local level. This analysis assumes a population based approach using the Canterbury Register of Insulin-treated diabetic persons as the study population. Diabetes discharge rates were found to be most highly correlated with hospital bed supply in 5 of the 8 years studied (1979-1986). Stepwise regression analysis indicated area rates of diabetes hospitalization were significantly influenced by resource factors even after controlling for differences in the socio-demographic characteristics of the area populations. This confirmed the presence of Roemer's Law at the aggregate level with rates of diabetes hospitalization appearing to have more to do with the availability of medical resources than to population needs. At the local level, hospital admission patterns were found to vary by general practitioner age, practice type found to vary by general practitioner age, practice type and diabetic caseload. Overall, insulin-treated diabetic patients most likely to be hospitalized were those in the care of young doctors new to general practice, and those who attended doctors who had small diabetic caseloads. Solo practitioners had the lowest rates of patient hospitalization. There were marked disparities in patient access to specialist diabetes education and clinical outpatient services by patient age, duration of diabetes and attendance on primary care. Overall, no significant differences were found in the propensity for hospitalization between users and non-users of these specialist services. This does not imply however, service ineffectiveness but rather is indicative of the complexity of the local diabetes care organization and the differing needs of the insulin-treated diabetic population within the community as a whole.
本文对医疗保健系统对住院模式的影响进行了宏观和微观层面的分析。以糖尿病这一健康疾病为例进行研究，分析基于新西兰的数据集。文章首先考察初级和二级医疗保健的供应及组织对住院率的影响程度。宏观层面的分析探讨了罗默法则在糖尿病住院区域差异方面的适用性。随后在地方层面研究通过医生把关功能对医院利用情况的组织控制以及医疗服务之间的相互作用。该分析采用基于人群的方法，以坎特伯雷胰岛素治疗糖尿病患者登记册作为研究人群。在研究的8年中的5年（1979 - 1986年），发现糖尿病出院率与医院床位供应的相关性最高。逐步回归分析表明，即使在控制了地区人口社会人口特征差异之后，糖尿病住院的地区率仍受到资源因素的显著影响。这证实了在总体层面上存在罗默法则，糖尿病住院率似乎更多地与医疗资源的可获得性有关，而非人口需求。在地方层面，发现医院入院模式因全科医生年龄、执业类型以及糖尿病病例数量而有所不同。总体而言，最有可能住院的胰岛素治疗糖尿病患者是那些由初涉全科医疗的年轻医生诊治的患者，以及那些就诊于糖尿病病例数量较少的医生的患者。个体执业医生的患者住院率最低。患者在获得糖尿病专科教育和临床门诊服务方面，因患者年龄、糖尿病病程以及接受初级保健的情况存在显著差异。总体而言，这些专科服务的使用者和非使用者在住院倾向方面未发现显著差异。然而，这并不意味着服务无效，而是表明当地糖尿病护理组织的复杂性以及整个社区内胰岛素治疗糖尿病患者群体的不同需求。
