R&D Centre, Skaraborg Primary Care, Skövde, Sweden.
Social Epidemiology, Department of Clinical Science, Faculty of Medicine, Lund University, Malmö, Sweden.
Eur J Clin Pharmacol. 2011 Apr;67(4):415-423. doi: 10.1007/s00228-010-0973-4. Epub 2010 Dec 29.
In Skaraborg, Sweden, the economic responsibility for tax-financed prescription drug costs was transferred from the regional administrative level to the local level (health care centre; HCC) in 2003. The aim of this study was to investigate the impact of this decentralization of economic responsibility on adherence to guidelines for prescribing lipid-lowering drugs.
Data from all 24 public HCCs in Skaraborg on prescriptions for lipid-lowering drugs during 2003 and 2005 were extracted from the Skaraborg Primary Care Database (SPCD). Multilevel regression analysis (MLRA) was used to disentangle the variances at different levels of data (patient, physician, HCC). The outcome variable on the patient level was the prescription of the recommended statin (yes/no). Sex and age of the patients and sex, age and occupational status of the physician were included as fixed effects. The variance was expressed as the median odds ratio (MOR).
The prevalence of adherence to guidelines for the prescription of statins increased from 77% in 2003 to 84% in 2005. The MLRA showed that in 2003 the variance was equally distributed between the HCC and physician levels (MOR(HCC2003)=1.89 vs. MOR(PHYSICIAN2003)=1.88). The variance between physicians and between HCCs decreased considerably between 2003 and 2005. The inclusion of individual and physician characteristics did not explain any of the remaining variance.
The decentralized budget appears to have increased adherence to guidelines and reduced inefficient variation in prescribing.
在瑞典的斯科讷省，2003 年将税收资助的处方药费用的经济责任从地区行政级别转移到地方级别（医疗保健中心；HCC）。本研究旨在调查这种经济责任分散化对遵循降脂药物处方指南的影响。
从斯科讷初级保健数据库（SPCD）中提取了 2003 年和 2005 年斯科讷省所有 24 个公共 HCC 开具的降脂药物处方数据。采用多水平回归分析（MLRA）来分解数据（患者、医生、HCC）不同层面的方差。患者层面的结果变量是开具推荐的他汀类药物（是/否）。患者的性别和年龄以及医生的性别、年龄和职业状况被纳入固定效应。方差表示为中位数优势比（MOR）。
2003 年至 2005 年，遵循他汀类药物处方指南的比例从 77%增加到 84%。MLRA 显示，2003 年 HCC 和医生层面的方差分布相当（MOR（HCC2003）=1.89 与 MOR（PHYSICIAN2003）=1.88）。医生之间和 HCC 之间的方差在 2003 年至 2005 年间显著降低。纳入个体和医生特征并不能解释任何剩余的方差。
分散的预算似乎增加了对指南的遵循，并减少了处方的低效变化。
