Yano Elizabeth M, Soban Lynn M, Parkerton Patricia H, Etzioni David A
VA Greater Los Angeles HSR&D Center of Excellence, Sepulveda VA Ambulatory Care Center, Sepulveda, CA 91343, USA.
Health Serv Res. 2007 Jun;42(3 Pt 1):1130-49. doi: 10.1111/j.1475-6773.2006.00643.x.
To identify primary care practice characteristics associated with colorectal cancer (CRC) screening performance, controlling for patient-level factors.
DATA SOURCES/STUDY SETTING: Primary care director survey (1999-2000) of 155 VA primary care clinics linked with 38,818 eligible patients' sociodemographics, utilization, and CRC screening experience using centralized administrative and chart-review data (2001).
Practices were characterized by degrees of centralization (e.g., authority over operations, staffing, outside-practice influence); resources (e.g., sufficiency of nonphysician staffing, space, clinical support arrangements); and complexity (e.g., facility size, academic status, managed care penetration), adjusting for patient-level covariates and contextual factors.
DATA COLLECTION/EXTRACTION METHODS: Chart-based evidence of CRC screening through direct colonoscopy, sigmoidoscopy, or consecutive fecal occult blood tests, eliminating cases with documented histories of CRC, polyps, or inflammatory bowel disease.
After adjusting for sociodemographic characteristics and health care utilization, patients were significantly more likely to be screened for CRC if their primary care practices had greater autonomy over the internal structure of care delivery (p<.04), more clinical support arrangements (p<.03), and smaller size (p<.001).
Deficits in primary care clinical support arrangements and local autonomy over operational management and referral procedures are associated with significantly lower CRC screening performance. Competition with hospital resource demands may impinge on the degree of internal organization of their affiliated primary care practices.
确定与结直肠癌（CRC）筛查表现相关的初级保健实践特征，并控制患者层面的因素。
数据来源/研究背景：对155家退伍军人事务部初级保健诊所进行的初级保健主任调查（1999 - 2000年），并通过集中管理的行政数据和病历审查数据（2001年）将其与38818名符合条件患者的社会人口统计学、医疗服务利用情况及CRC筛查经历相联系。
根据集中化程度（如对运营、人员配备、外部实践影响的权限）、资源（如非医师人员配备充足程度、空间、临床支持安排）和复杂性（如机构规模、学术地位、管理式医疗渗透程度）对各实践进行特征描述，并对患者层面的协变量和背景因素进行调整。
数据收集/提取方法：通过直接结肠镜检查、乙状结肠镜检查或连续粪便潜血试验获取基于病历的CRC筛查证据，排除有CRC、息肉或炎症性肠病病史记录的病例。
在调整社会人口统计学特征和医疗服务利用情况后，如果患者的初级保健实践在医疗服务内部结构方面具有更大自主权（p <.04）、更多临床支持安排（p <.03）且规模较小（p <.001），则这些患者接受CRC筛查的可能性显著更高。
初级保健临床支持安排不足以及在运营管理和转诊程序方面缺乏地方自主权与CRC筛查表现显著降低相关。与医院资源需求的竞争可能会影响其附属初级保健实践的内部组织程度。
