诊断实践的地区差异。
Regional variations in diagnostic practices.
机构信息
Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH, USA.
出版信息
N Engl J Med. 2010 Jul 1;363(1):45-53. doi: 10.1056/NEJMsa0910881. Epub 2010 May 12.
BACKGROUND
Current methods of risk adjustment rely on diagnoses recorded in clinical and administrative records. Differences among providers in diagnostic practices could lead to bias.
METHODS
We used Medicare claims data from 1999 through 2006 to measure trends in diagnostic practices for Medicare beneficiaries. Regions were grouped into five quintiles according to the intensity of hospital and physician services that beneficiaries in the region received. We compared trends with respect to diagnoses, laboratory testing, imaging, and the assignment of Hierarchical Condition Categories (HCCs) among beneficiaries who moved to regions with a higher or lower intensity of practice.
RESULTS
Beneficiaries within each quintile who moved during the study period to regions with a higher or lower intensity of practice had similar numbers of diagnoses and similar HCC risk scores (as derived from HCC coding algorithms) before their move. The number of diagnoses and the HCC measures increased as the cohort aged, but they increased to a greater extent among beneficiaries who moved to regions with a higher intensity of practice than among those who moved to regions with the same or lower intensity of practice. For example, among beneficiaries who lived initially in regions in the lowest quintile, there was a greater increase in the average number of diagnoses among those who moved to regions in a higher quintile than among those who moved to regions within the lowest quintile (increase of 100.8%; 95% confidence interval [CI], 89.6 to 112.1; vs. increase of 61.7%; 95% CI, 55.8 to 67.4). Moving to each higher quintile of intensity was associated with an additional 5.9% increase (95% CI, 5.2 to 6.7) in HCC scores, and results were similar with respect to laboratory testing and imaging.
CONCLUSIONS
Substantial differences in diagnostic practices that are unlikely to be related to patient characteristics are observed across U.S. regions. The use of clinical or claims-based diagnoses in risk adjustment may introduce important biases in comparative-effectiveness studies, public reporting, and payment reforms.
背景
目前的风险调整方法依赖于临床和行政记录中记录的诊断。不同提供者在诊断实践方面的差异可能导致偏差。
方法
我们使用了 1999 年至 2006 年的 Medicare 索赔数据，以衡量 Medicare 受益人的诊断实践趋势。根据受益地区获得的医院和医生服务的强度，将地区分为五个五分位组。我们比较了受益人与实践强度较高或较低的地区转移时，诊断、实验室检查、影像学检查和层次条件类别（HCC）分配方面的趋势。
结果
在研究期间，每个五分位组内的受益人均在向实践强度较高或较低的地区转移之前，具有相似数量的诊断和相似的 HCC 风险评分（源自 HCC 编码算法）。随着队列年龄的增长，诊断数量和 HCC 指标增加，但在向实践强度较高的地区转移的受益人中增加幅度大于向实践强度相同或较低的地区转移的受益人中。例如，在最初居住在最低五分位组地区的受益人中，与向最低五分位组地区转移的人相比，向较高五分位组地区转移的人平均诊断数量增加更多（增加 100.8%；95%置信区间 [CI]，89.6 至 112.1；vs. 增加 61.7%；95% CI，55.8 至 67.4）。转移到每个更高强度五分位组与 HCC 评分增加 5.9%（95% CI，5.2 至 6.7）相关，实验室检查和影像学检查也有类似结果。
结论
在美国各地区观察到临床诊断实践方面存在大量差异，这些差异不太可能与患者特征有关。在风险调整中使用临床或索赔诊断可能会在比较有效性研究、公共报告和支付改革中引入重要偏差。
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