Robra B-P, Kania H, Kuss O, Schönfisch K, Swart E
Institut für Sozialmedizin und Gesundheitsökonomie der Otto-von-Guericke-Universität Magdeburg.
Gesundheitswesen. 2006 Jan;68(1):32-40. doi: 10.1055/s-2005-858903.
Unexplained differences in the density of in-patient management in one federal state in Germany led to a regional survey of physicians in independent and hospital practice, which aimed to describe more precisely the determinants of referral and admission behaviour. Brief typical case descriptions (vignettes) were designed, as an instrument of data collection, dealing with two examples of management problems: upper and lower abdominal pain. The urgency of inpatient treatment was ranked using clinical scores and guidelines. Social characteristics for the patient (age, gender, social situation, preference for/against hospitalisation, day of the week on which the patient presented) were randomly assigned to the case vignettes. Each physician was asked by mail to decide on the management of 10 upper and 10 lower abdominal vignettes each. The physicians were also asked to provide additional information on the characteristics of their practice or hospital. The data were analysed using multivariate hierarchical models. A 28 % response rate meant that vignettes were available from 455 general practitioners and internal medicine specialists in independent practice, as well as 261 hospital surgeons and internal medicine specialists, together with responses from 31 physicians from the medical service of the German statutory health insurance (MDK). 7376 upper abdominal and 7335 lower abdominal vignettes were analysed. Admission rates reflected the graded severity of the symptoms built into the vignettes. Hospital physicians wanted to admit the vignette patients much more frequently than physicians in independent practice wished to refer them. Older patients, independent of symptoms, were more frequently referred or admitted than younger patients. In the case of acute symptoms it is the day of the week when the patient consulted the physician and in the case of elective surgery the patient's preference that are important for hospitalisation. The results show that medical decisions on case management are made using reasonable problem-specific preferences. The probability of actually instigating admission was, other things being equal, much higher in hospital physicians than in office-based physicians. As an instrument of comparative research into medical care, case vignettes have practical advantages in relation to medical audits and standardised patients. They can also be used for teaching, examining, documenting and quality assurance purposes.
德国某联邦州住院治疗管理密度存在不明差异，为此开展了一项针对独立执业和医院执业医生的地区性调查，旨在更精确地描述转诊和收治行为的决定因素。设计了简短的典型病例描述（案例 vignettes）作为数据收集工具，涉及两个管理问题示例：上腹部疼痛和下腹部疼痛。使用临床评分和指南对住院治疗的紧迫性进行排序。将患者的社会特征（年龄、性别、社会状况、住院偏好/反对意见、患者就诊的星期几）随机分配到病例 vignettes 中。通过邮件要求每位医生对 10 个上腹部和 10 个下腹部 vignettes 进行管理决策。还要求医生提供有关其执业或医院特征的额外信息。使用多元分层模型对数据进行分析。28% 的回复率意味着从 455 名独立执业的全科医生和内科专家、261 名医院外科医生和内科专家以及德国法定医疗保险医疗服务机构（MDK）的 31 名医生那里获得了 vignettes 回复。共分析了 7376 个上腹部 vignettes 和 7335 个下腹部 vignettes。收治率反映了 vignettes 中设定的症状分级严重程度。医院医生比独立执业医生更频繁地希望收治 vignettes 患者。与症状无关，老年患者比年轻患者更频繁地被转诊或收治。对于急性症状，患者就诊的星期几对住院治疗很重要；对于择期手术，患者的偏好很重要。结果表明，关于病例管理的医疗决策是基于合理的特定问题偏好做出的。在其他条件相同的情况下，医院医生实际促成收治的概率比门诊医生高得多。作为医疗保健比较研究的工具，病例 vignettes 在医疗审计和标准化患者方面具有实际优势。它们还可用于教学、考试、记录和质量保证目的。
