DeSalvo Karen B, Block Jason P, Muntner Paul, Merrill William
Section of General Internal Medicine, Tulane School of Public Health, Department of Epidemiology, New Orleans, LA 70012, USA.
Int J Qual Health Care. 2003 Oct;15(5):399-405. doi: 10.1093/intqhc/mzg067.
Despite the important influence of ambulatory appointment revisit intervals (RVI) on access to care, physicians receive no formal training in this area and research indicates that there is significant practice variation. Our objective was to examine whether predictors of RVI assignment that we had assessed using vignettes were also significant in the actual patient care setting.
A cross-sectional survey of 59 internal medicine residents collected at the end of office visits for patients with hypertension or diabetes. Two hundred and twenty-eight patients seen in 1997 for continuity care in two academic clinics in New Orleans, Louisiana.
The main outcome was RVI in weeks. We assessed the relationship between physician, visit, and patient-level covariates, and RVI assignment in univariate and multivariate analyses using hierarchical linear models.
The mean RVI was 12.4 weeks (range 1-42 weeks) and was similar for patients with diabetes and hypertension. The final model accounted for 35.7% of the variance in RVI assignment and included: perceptions of the patient's systolic blood pressure, disease stability, and compliance; comorbidity, physician age, sex, and identity; and changing therapy for the primary diagnosis. The identity of the physician was the largest contributor to the variance, accounting for 14.7%.
Intrinsic characteristics of physicians and their subjective interpretations of their patients' disease stability are the most important determinants of ambulatory RVI assignment. Intervening to reduce this variation in practice is challenging because limited research is currently available on the optimum RVI for patients with chronic illnesses such as diabetes and hypertension.
尽管门诊预约复诊间隔时间（RVI）对获得医疗服务有重要影响，但医生在这方面未接受过正规培训，且研究表明实践中存在显著差异。我们的目的是检验我们使用病例 vignettes 评估的 RVI 分配预测因素在实际患者护理环境中是否也具有显著性。
对 59 名内科住院医师在高血压或糖尿病患者门诊就诊结束时进行的横断面调查。1997 年在路易斯安那州新奥尔良市的两家学术诊所对 228 名接受连续性护理的患者进行了观察。
主要结局是按周计算的 RVI。我们使用分层线性模型在单变量和多变量分析中评估了医生、就诊和患者层面协变量与 RVI 分配之间的关系。
平均 RVI 为 12.4 周（范围 1 - 42 周），糖尿病和高血压患者的情况相似。最终模型解释了 RVI 分配中 35.7%的方差，包括：对患者收缩压的认知、疾病稳定性和依从性；合并症、医生年龄、性别和身份；以及针对主要诊断的治疗变化。医生身份对方差的贡献最大，占 14.7%。
医生的内在特征及其对患者疾病稳定性的主观解读是门诊 RVI 分配的最重要决定因素。减少这种实践差异具有挑战性，因为目前关于糖尿病和高血压等慢性病患者最佳 RVI 的研究有限。
