Maly R C, Abrahamse A F, Hirsch S H, Frank J C, Reuben D B
Division of Family Medicine, University of California-Los Angeles School of Medicine, USA.
Arch Fam Med. 1996 Sep;5(8):448-54. doi: 10.1001/archfami.5.8.448.
Comprehensive geriatric assessment (CGA) in outpatient settings has not been shown to be as effective in reducing mortality and improving health as in hospital settings; this difference has been attributed in part to a lack of direct control over recommendation implementation.
To identify inhibiting and facilitating factors in physicians' compliance with consultative CGA recommendations, so that the effectiveness of outpatient CGA might be improved.
A 49-item questionnaire was administered via the telephone to 87 eligible community primary care physicians in Los Angeles, Calif, whose patients had received consultative outpatient CGAs as part of a study of CGA (response rate, 96%). The questionnaire assessed physician compliance with CGA recommendations, reasons for implementing or not implementing the recommendations, and specific physician attitudes, perceptions, and characteristics. The focus of the interview was the CGA recommendation that was determined to be the "most important" by the evaluating geriatrician. Recommendations addressed geriatric syndromes, general medical problems, or psychiatric conditions.
Of the 87 physician respondents, 62 (71%) implemented the most important recommendation. In multivariate analysis, 4 variables were predictive of physician compliance: (1) a patient's request that the recommendation be implemented (odds ratio [OR], 10.8; 95% confidence interval [CI], 1.9-61.3; P = .007); (2) perceived legal liability resulting from nonimplementation of the recommendation (OR, 10.8; 95% CI, 1.1-108.2; P = .04); (3) female physician gender (OR, 9.6; 95% CI, 1.4-67.9; P = .04); and (4) perceived cost-effectiveness of the recommendation (OR, 7.0; 95% CI, 1.6-30.5; P = .01).
Patient behavior, which may be modifiable, was among the strongest determinants of physician compliance with recommended care. Specifically, when patients requested that a recommendation be implemented, physicians were highly likely to comply. Changing patient behavior within the physician-patient relationship as a way of effecting desired changes in physician health care practices merits further attention.
门诊环境下的综合老年评估（CGA）在降低死亡率和改善健康方面并未显示出与住院环境下同样有效；这种差异部分归因于对建议实施缺乏直接控制。
确定医生遵守咨询性CGA建议的阻碍因素和促进因素，以便提高门诊CGA的有效性。
通过电话向加利福尼亚州洛杉矶市87名符合条件的社区初级保健医生发放一份包含49个条目的问卷，这些医生的患者作为CGA研究的一部分接受了咨询性门诊CGA（回复率为96%）。该问卷评估医生对CGA建议的遵守情况、实施或不实施建议的原因以及医生的具体态度、看法和特征。访谈重点是评估老年病医生确定为“最重要”的CGA建议。建议涉及老年综合征、一般医疗问题或精神疾病状况。
在87名医生受访者中，62名（71%）实施了最重要的建议。在多变量分析中，4个变量可预测医生的遵守情况：（1）患者要求实施该建议（比值比[OR]，10.8；95%置信区间[CI]，1.9 - 61.3；P = 0.007）；（2）认为不实施建议会导致法律责任（OR，10.8；95% CI，1.1 - 108.2；P = 0.04）；（3）女性医生（OR，9.6；95% CI，1.4 - 67.9；P = 0.04）；（4）认为建议具有成本效益（OR，7.0；95% CI，1.6 - 30.5；P = 0.01）。
患者行为（可能是可改变的）是医生遵守推荐治疗的最强决定因素之一。具体而言，当患者要求实施建议时，医生很可能会遵守。在医患关系中改变患者行为以实现医生医疗保健实践中的期望改变值得进一步关注。
