Davis P B, Yee R L, Millar J
Department of Community Health, School of Medicine, University of Auckland, New Zealand.
Soc Sci Med. 1994 Aug;39(3):367-74. doi: 10.1016/0277-9536(94)90133-3.
Medical practice variation is extensive and well documented, particularly for surgical interventions, and raises important questions for health policy. To date, however, little work has been carried out on interpractitioner variation in prescribing activity in the primary care setting. An analytical model of medical variation is derived from the literature and relevant indicators are identified from a study of New Zealand general practice. The data are based on nearly 9,500 completed patient encounter records drawn from over a hundred practitioners in the Waikato region of the North Island, New Zealand. The data set represents a 1% sample of all weekday general practice office encounters in the Hamilton Health District recorded over a 12-month period. Overall levels of prescribing, and the distribution of drug mentions across diagnostic groupings, are broadly comparable to results drawn from international benchmark data. A multivariate analysis is carried out on seven measures of activity in the areas of prescribing volume, script detail, and therapeutic choice. The analysis indicates that patient, practitioner and practice attributes exert little systematic influence on the prescribing task. The principal influences are diagnosis, followed by practitioner identity. The pattern of findings suggests also that the prescribing task cannot be viewed as an undifferentiated activity. It is more usefully considered as a process of decision-making in which 'core' judgements--such as the decision to prescribe and the choice of drug--are highly predictable and strongly influenced by diagnosis, while 'peripheral' features of the task--such as choosing a combination drug or prescribing generically--are less determinate and more subject to the exercise of clinical discretion.(ABSTRACT TRUNCATED AT 250 WORDS)
医疗实践差异广泛且有充分记录，尤其是在外科手术干预方面，这对卫生政策提出了重要问题。然而，迄今为止，关于初级保健环境中处方活动的从业者间差异的研究甚少。从文献中推导了一个医疗差异分析模型，并从新西兰全科医疗研究中确定了相关指标。数据基于从新西兰北岛怀卡托地区一百多名从业者那里获取的近9500份完整的患者诊疗记录。该数据集代表了汉密尔顿健康区在12个月期间记录的所有工作日全科医疗办公室诊疗的1%样本。总体处方水平以及各诊断分组中药物提及的分布情况与国际基准数据得出的结果大致相当。对处方量、处方细节和治疗选择等领域的七项活动指标进行了多变量分析。分析表明，患者、从业者和医疗机构属性对处方任务几乎没有系统性影响。主要影响因素是诊断，其次是从业者身份。研究结果模式还表明，处方任务不能被视为一项无差异的活动。更有用的是将其视为一个决策过程，其中“核心”判断——如开处方的决定和药物选择——具有高度可预测性且受诊断强烈影响，而任务的“外围”特征——如选择复方药物或开通用名药物——则较不确定且更受临床判断力的影响。（摘要截取自250词）
