Von Korff M R, Howard J A, Truelove E L, Sommers E, Wagner E H, Dworkin S
Center for Health Studies, ACC, Group Health Cooperative of Puget Sound, Seattle, WA 98121.
Med Care. 1988 Mar;26(3):307-14.
This research describes the extent of variability in diagnosis and treatment of temporomandibular disorders (TMD) and relates this variability to treatment outcomes. A health maintenance organization sequentially referred 145 patients with orofacial pain and dysfunction to two TMD clinics. The two clinics differed substantially in their use of tomography (applied to 28% vs. 64% of all patients), and varied moderately in diagnoses assigned to the patient groups. There was large variation in selection of treatments including appliances for bruxism (64% vs. 5%), mandibular repositioning (10% vs. 25%), and joint stabilization (3% vs. 30%); anti-inflammatory medications (44% vs. 19%) and analgesics (16% vs. 2%); and subsequent referral for dental or orthodontic treatment (1% vs. 42%). The differences in diagnostic and therapeutic practice that were found were not associated with important differences in patient-reported pain and dysfunction at 1-year follow-up. These data indicate the need for systematic approaches to identifying, evaluating, and modifying variation in health care practices for common presenting problems lacking reliable methods of evaluation and generally accepted clinical standards for choice of treatments.
本研究描述了颞下颌关节紊乱病（TMD）诊断和治疗的差异程度，并将这种差异与治疗结果相关联。一家健康维护组织先后将145例有口面部疼痛和功能障碍的患者转诊至两家TMD诊所。两家诊所在断层扫描的使用上有很大差异（分别应用于所有患者的28%和64%），对患者组的诊断也有适度差异。在治疗选择上存在很大差异，包括磨牙症矫治器（64%对5%）、下颌重新定位（10%对25%）和关节稳定（3%对30%）；抗炎药物（44%对19%）和镇痛药（16%对2%）；以及随后转诊进行牙科或正畸治疗（1%对42%）。在1年随访时，所发现的诊断和治疗实践差异与患者报告的疼痛和功能障碍方面的重要差异无关。这些数据表明，对于缺乏可靠评估方法和普遍接受的治疗选择临床标准的常见就诊问题，需要采用系统方法来识别、评估和改变医疗保健实践中的差异。
