Leslie Douglas L, Rosenheck Robert A
Department of Psychiatry, Yale School of Medicine, VA Connecticut Mental Illness Research, Education and Clinical Center, West Haven VAMC, West Haven, CT 06516, USA.
J Ment Health Policy Econ. 2003 Sep;6(3):113-21.
Comparing quality of care between large health care systems is important for health systems management. This study used measures of the quality of pharmacotherapy for patients with schizophrenia and compared these measures across a sample of patients from the Department of Veterans Affairs (VA) and the private sector.
A random sample of all patients diagnosed with schizophrenia in the VA during fiscal year (FY) 2000 was identified using administrative data. In the private sector, a sample of patients diagnosed with schizophrenia in 2000 was identified using MEDSTAT's MarketScan database. For both groups, use of antipsychotic medications was studied and measures of the quality of pharmacotherapy were constructed, including whether patients were prescribed any antipsychotic medication, one of the newer atypical antipsychotics, and whether dosing adhered to established treatment recommendations. These measures were compared across the two groups using logistic regression models, controlling for age, gender, and comorbid diagnoses.
Most patients with a diagnosis of schizophrenia (82% in the VA and 73% in the private sector) received an antipsychotic medication, usually one of the newer atypical drugs. Patients in the VA were more likely to be dosed above treatment recommendations, and less likely to be dosed below treatment recommendations. Overall, differences in proportion schizophrenia patients dosed according to recommendations were not statistically different across the two systems (60% in the VA, 58% in the private sector).
Differences between the two systems were mixed, with the VA outperforming the private sector with respect to some measures and doing worse on others.
Although the VA and the private sector were comparable with respect to the quality measures used in this study, there is room for improvement in both systems. Treatment recommendations are based on the best available clinical evidence of effectiveness and safety. Quality of care might be improved with better adherence to these recommendations.
Relatively low rates of adherence to treatment recommendations may be due to lack of awareness of these recommendations among prescribing physicians, or a belief that the recommendations are inadequate. To the extent that low rates of adherence to treatment recommendations are caused by a lack of awareness among physicians, policies should be developed to disseminate this information and encourage the appropriate use of these medications.
Further research is needed to understand physician prescribing decisions for these medications. To the extent that physicians feel treatment recommendations for these drugs are inadequate, further research is needed to refine the recommendations.
比较大型医疗保健系统之间的医疗质量对于卫生系统管理至关重要。本研究采用了精神分裂症患者药物治疗质量的衡量指标，并在退伍军人事务部（VA）和私营部门的患者样本中对这些指标进行了比较。
利用行政数据确定了2000财年VA中所有被诊断为精神分裂症患者的随机样本。在私营部门，利用MEDSTAT的市场扫描数据库确定了2000年被诊断为精神分裂症患者的样本。对两组患者，研究了抗精神病药物的使用情况，并构建了药物治疗质量的衡量指标，包括患者是否被开具了任何抗精神病药物、是否开具了新型非典型抗精神病药物之一，以及给药是否符合既定的治疗建议。使用逻辑回归模型对两组的这些指标进行了比较，并对年龄、性别和合并症诊断进行了控制。
大多数被诊断为精神分裂症的患者（VA中为82%，私营部门中为73%）接受了抗精神病药物治疗，通常是新型非典型药物之一。VA中的患者更有可能超过治疗建议剂量给药，而低于治疗建议剂量给药的可能性较小。总体而言，两个系统中按照建议给药的精神分裂症患者比例差异无统计学意义（VA中为60%，私营部门中为58%）。
两个系统之间的差异参差不齐，VA在某些指标上表现优于私营部门，而在其他指标上则表现较差。
尽管VA和私营部门在本研究中使用的质量指标方面具有可比性，但两个系统都有改进的空间。治疗建议基于现有的最佳有效性和安全性临床证据。更好地遵循这些建议可能会提高医疗质量。
对治疗建议的遵循率相对较低可能是由于开处方医生对这些建议缺乏认识，或者认为这些建议不够充分。如果对治疗建议的低遵循率是由医生缺乏认识导致的，就应该制定政策来传播这些信息，并鼓励合理使用这些药物。
需要进一步研究以了解医生对这些药物的处方决策。如果医生认为这些药物的治疗建议不够充分，就需要进一步研究以完善这些建议。
