Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK.
BMJ Qual Saf. 2020 Apr;29(4):296-303. doi: 10.1136/bmjqs-2019-009469. Epub 2019 Oct 5.
To examine how much of the variation between general practices in referral rates and cancer detection rates is attributable to local health services rather than the practices or their populations.
Ecological analysis of national data on fast-track referrals for suspected cancer from general practices. Data were analysed at the levels of general practice, primary care organisation (Clinical Commissioning Group) and secondary care provider (Acute Hospital Trust) level. Analysis of variation in detection rate was by multilevel linear and Poisson regression.
6379 group practices with data relating to more than 50 cancer cases diagnosed over the 5 years from 2013 to 2017.
Proportion of observed variation attributable to primary and secondary care organisations in standardised fast-track referral rate and in cancer detection rate before and after adjustment for practice characteristics.
Primary care organisation accounted for 21% of the variation between general practices in the standardised fast-track referral rate and 42% of the unadjusted variation in cancer detection rate. After adjusting for standardised fast-track referral rate, primary care organisation accounted for 31% of the variation in cancer detection rate (compared with 18% accounted for by practice characteristics). In areas where a hospital trust was the main provider for multiple primary care organisations, hospital trusts accounted for the majority of the variation attributable to local health services (between 63% and 69%).
This is the first large-scale finding that a substantial proportion of the variation between general practitioner practices in referrals is attributable to their local healthcare systems. Efforts to reduce variation need to focus not just on individual practices but on local diagnostic service provision and culture at the interface of primary and secondary care.
考察基层医疗实践中转诊率和癌症检出率的差异在多大程度上归因于当地卫生服务，而不是实践或其人群。
对基层医疗实践中疑似癌症的快速转诊国家数据进行生态分析。数据在基层医疗实践、初级保健组织（临床委托小组）和二级保健提供者（急性医院信托）层面进行分析。检测率的差异分析采用多水平线性和泊松回归。
6379 个基层医疗实践，数据涉及 2013 年至 2017 年的 5 年期间诊断出的 50 多例癌症。
在调整实践特征后，初级保健组织解释了标准化快速转诊率和癌症检出率之间观察到的差异的 21%和 42%。在调整标准化快速转诊率后，初级保健组织解释了癌症检出率变化的 31%（相比之下，实践特征解释了 18%）。在医院信托是多个初级保健组织主要提供者的地区，医院信托占归因于当地卫生服务的变化的大部分（63%至 69%）。
这是第一个大规模的发现，即基层医疗实践中转诊的差异有相当大的一部分归因于他们当地的医疗保健系统。减少差异的努力不仅需要关注个体实践，还需要关注初级和二级保健之间接口的本地诊断服务提供和文化。
