Gittelsohn A, Powe N R
School of Hygiene and Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
Health Serv Res. 1995 Jun;30(2):295-317.
Our purpose is a descriptive analysis of variations in hospital use among small areas of Maryland.
The data are Maryland patient discharge records from acute care hospitals for 1985-1987 and small area population estimates by age, gender, race, and income.
The common finding was excess geographic variability among Maryland's 115 areas. The hypothesis of uniform rates was rejected for most DRGs, including low-variation mastectomy and hernia repair. Clustering of high-use rates occurred in neighboring areas for orthopedic, vascular, and elective procedures. Admission rates for most nondiscretionary procedures and medical DRGs were reduced in affluent areas while discretionary surgery increased with income level. Elective procedures had extreme variation and were related to income. Coronary artery disease rates declined with income while coronary artery procedure rates increased, indicating that access and patient selection were factors in the use of coronary bypass and angioplasty.
The issue is not the ubiquitous variation among small areas but its extent and identification of geographic patterns. Hospital use is related to demography, morbidity, medical resources, access, selection for care, and physician practice patterns. Heterogeneity of these factors ensures that uniform delivery of health care rarely holds. There is little evidence that incidence of surgical disease is the main source of variation in use of discretionary surgery. Rather, variations reflect differing medical opinion on appropriate use. Without evaluation, excessive use cannot be distinguished from underservice. Morbidity explains the variability of nondiscretionary surgery and conditions related to lifestyle. Access plays an important role for discretionary surgery. Geographic analysis can identify variation and relate incidence to socioeconomic and specific local effects. Hospital data do not permit direct assessment of appropriate care. Understanding the reasons for variation requires information beyond incidence data. The challenge is to identify and explain small area variations or to fix them.
我们旨在对马里兰州小区域内医院使用情况的差异进行描述性分析。
数据为1985 - 1987年马里兰州急性护理医院的患者出院记录以及按年龄、性别、种族和收入划分的小区域人口估计数。
常见的发现是马里兰州115个区域存在过度的地理差异。对于大多数诊断相关分组（DRG），包括低差异的乳房切除术和疝气修补术，均匀费率的假设被拒绝。在骨科、血管和择期手术方面，高使用率在相邻区域出现聚集。在富裕地区，大多数非 discretionary 手术和医疗DRG的入院率降低，而 discretionary 手术随着收入水平的提高而增加。择期手术差异极大且与收入相关。冠状动脉疾病发病率随收入下降，而冠状动脉手术率上升，这表明在冠状动脉搭桥术和血管成形术的使用中，可及性和患者选择是因素。
问题不在于小区域之间普遍存在的差异，而在于其程度以及地理模式的识别。医院使用情况与人口统计学、发病率、医疗资源、可及性、护理选择以及医生的执业模式有关。这些因素的异质性确保了很少能实现统一的医疗服务提供。几乎没有证据表明外科疾病的发病率是 discretionary 手术使用差异的主要来源。相反，差异反映了对适当使用的不同医学观点。未经评估，过度使用与服务不足无法区分。发病率解释了非 discretionary 手术和与生活方式相关疾病的变异性。可及性在 discretionary 手术中起重要作用。地理分析可以识别差异并将发病率与社会经济和特定的局部影响联系起来。医院数据不允许直接评估适当的护理。理解差异的原因需要发病率数据之外的信息。挑战在于识别和解释小区域差异或解决这些差异。
